Testing the Effectiveness of Behavioral Activation Therapy in the Treatment of Acute Unipolar Depression

Western Michigan University ScholarWorks at WMU

Dissertations Graduate College

12-2002

Jenifer M. Cullen Western Michigan University

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Recommended Citation Cullen, Jenifer M., "Testing the Effectiveness of Behavioral Activation Therapy in the Treatment of Acute Unipolar Depression" (2002). Dissertations. 1266. https://scholarworks.wmich.edu/dissertations/1266

This Dissertation-Open Access is brought to you for free and open access by the Graduate College at ScholarWorks at WMU. It has been accepted for inclusion in Dissertations by an authorized administrator of ScholarWorks at WMU. For more information, please contact [email protected]. TESTING THE EFFECTIVENESS OF BEHAVIORAL ACTIVATION THERAPY IN THE TREATMENT OF ACUTE UNIPOLAR DEPRESSION

Jenifer M. Cullen

A Dissertation Submitted to the Faculty o f The Graduate College in partial fulfillment of the requirements for the Degree o f Doctor o f Philosophy Department of Psychology

Western Michigan University Kalamazoo, Michigan December 2002

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. TESTING THE EFFECTIVENESS OF BEHAVIORAL ACTIVATION THERAPY IN THE TREATMENT OF ACUTE UNIPOLAR DEPRESSION

Jenifer M. Cullen, Ph.D.

Western Michigan University, 2002

The present study sought to investigate the clinical effectiveness o f Behavioral

Activation (BA) Therapy, the behavioral activation component of Beck's Cognitive

Therapy (CT; Beck, Rush, Shaw, & Emery, 1979). Seventeen adults seeking mental

health services for Unipolar Depression were recruited from the Kalamazoo and

Southwestern Michigan regions. All participants were randomly assigned to either

(a) an Immediate Treatment Group, or (b) a waitlist control group, while both

received 10 weeks of BA therapy. Depressive symptomatology for both conditions

were assessed at pretreatment, post-treatment, and 3-month follow-up with the Beck

Depression Inventory-II (BDI-II; Beck, Steer, Ball, & Ranieri, 1996), the Structured

Clinical Interview for the DSM-IV-Non-Patient Version (SCID; First, Spitzer,

Gibbon, & Williams, 1997), and the Revised Hamilton Rating Scale for Depression

(RHRSD; Warren, 1996). It was hypothesized that at the completion of treatment,

participants in both the immediate treatment and waitlist conditions would be

significantly less depressed both on a self-report measure and on clinician ratings of

severity of depression. It was further hypothesized that the waitlist participants

would show no significant change during the waitlist period.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Copyright by Jenifer M. Cullen 2002

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ACKNOWLEDGMENTS

I would like to first thank my mother, Pamm, and father, Steve, for their

unbridled support and encouragement throughout my graduate training. Without

them, I would not be where 1 am today.

I also extend my warmest gratitude to my advisor, Dr. C. Richard Spates. It

was his enthusiasm and consistent attention to this project and my well being that

fueled this investigation and my progress in the graduate program. Words cannot

express how lucky I feel to have been a student o f Dr. Spates’s.

I also thank my dissertation committee, Dr. Malcolm Robertson, Dr. Galen

Alessi, and Dr. Lisa Largo-Marsh for their efforts in the completion o f this

investigation, along with Dr. Lester Wright for his overall support throughout my

graduate training. And I cannot forget to mention, all the help I received from Donna

Areaux over the years. Finally, I thank Amy Wiseman for her statistical intellect and

input on this project. For you all, I am eternally grateful.

Jenifer M. Cullen

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. TABLE OF CONTENTS

ACKNOWLEDGMENTS______ii

LIST OF TABLES______vi

LIST OF FIGURES______vii

CHAPTER

L INTRODUCTION______1

Etiological Components of Unipolar Depression______3

Behavior Therapy Treatment Modalities...... 7

Cognitive Therapy Treatment Modalities------10

The Advent of Cognitive Behavioral Therapy______13

IL REVIEW OF THE LITERATURE______15

Evidence Support Behavior Therapy______15

Evidence Supporting Cognitive Therapy.------17

Evidence for Combined Treatment-Medication Plus Cognive Therapy------19

Combined Cognitive and Behavior Therapy______23

Dismantling of Cognitive Behavior Treatment______24

Problem Statement______27

HI. M ETHOD______30

Sam ple------30

Setting------31

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table of Contents—Continued

CHAPTER

Assessors and Therapists...... 32

Treatm ents...... 32

Treatment Integrity______36

Outcome Measures ...... 37

Procedure...... 43

IV. RESULTS ...... 48

Analysis Plan------48

Preliminary Analyses...... 51

Primary A nalyses------57

Intent-to-Treat Analysis______67

Post-hoc Analyses______68

Diagnostic Outcome and Recovery______73

Treatment Adherence______75

V. DISCUSSION______77

Main Outcomes------77

Secondary Outcomes______82

Limitations of This Study------86

Future Investigation and Conclusion______89

APPENDICES

A. HSIRB Approval Letter______93 iv

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APPENDICES

B. Treatment Integrity Checklist...... 95

C. Initial Recruitment Telephone Script...... 97

D. Consent Form...... 99

E. Demographics Questionnaire______102

F. Beck Depression Inventory—Second Edition...... 105

G. Revised Hamilton Rating Scale for Depression______107

H. M aster L ist______109

I. Universal Data Collection Form...... I l l

BIBLIOGRAPHY.______114

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. LIST OF TABLES

1. Demographic Variables for Completers, Dropouts, and the Total S am ple______52

2. Clinical Characteristics of Completers and Dropouts...... 54

3. Mean Pre-waitlist and Post-waitlist BDI-H Scores for Waitlist Participants and Mean Pretreatment, Post-treatment, and 3-Month Follow-up for BDI-II Scores for Treatment Participants______57

4. BDI-II and RHRSD Scores at Pretreatment______59

5. Pretreatment, Post-treatment, and 3-Month Follow-up Means for BDI-H and RHRSD Scores for the Total Sample------66

6. Pretreatment, Post-treatment, and 3-Month Follow-up Means for BDI-II and RHRSD Scores as a Function o f Medication Status______70

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. LIST OF FIGURES

1. Projected Therapeutic Gains on the BDI-H for the Total Sample by Condition...... 48

2. Mean Pre-waitlist and Post-waitlist BDI-H Scores for Waitlist Participants and Mean Pretreatment, Post-treatment, and 3-Month Follow-up BDI-II Scores for Treatment Participants...... 58

3. Mean BDI-H and RHRSD Scores at Pretreatm ent------59

A. Pretreatment, Post-treatment, and 3-Month Follow-up Means for BDI-II Scores by Condition...... 62

5. Pretreatment, Post-treatment, and 3-Month Follow-up Means for RHRSD Scores by Condition______62

6. Pretreatment, Post-treatment, and 3-Month Follow-up Means for BDI-II and RHRSD Scores for the Total Sample ...... 67

7. Mean BDI-II Scores as a Function of Medication Status______71

8. Mean RHRSD Scores as a Function of Medication Status______71

vii

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. CHAPTER I

INTRODUCTION

Unipolar Depression is a serious and debilitating mental disorder that afflicts a

large number of human beings worldwide. According to a National Comorbidity

Survey in the USA (Blazer, Kessler, McGonagle, & Swartz, 1994), approximately

4.9% of the population suffers from Unipolar Depression. This means that at any

given moment approximately 1 person in 20 is significantly depressed. Not only is

depression fairly widespread at any given time, but its lifetime prevalence is also

high. The National Comorbidity Survey indicates a lifetime prevalence rate of 17%

and a 12-month prevalence rate of 10.3% (Blazer et al., 1994; Hammen, 1997). As

noted by Lecrubier(200l), these numbers are expected to increase over the coming

decades. It has been estimated by the World Health Organization (WHO) Global

Burden o f Disease Survey that by the year 2020, major depression will be second

only to heart disease. Although depression is highly prevalent, it is difficult to know

exactly how many individuals suffer from depression at any one time. It seems these

numbers may be underestimated since only about 70% o f individuals with depression

seek treatment (Angst, 1998).

While depression directly afreets many people in the USA, even those in

society who are not direct victims are impacted. For instance, occupational

productivity is directly impacted by depression. According to Mintz, Mintz, Arruda,

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. & Hwang (1992), the workplace cost o f depression in the USA in terms of lost time at

work is estimated at more than 172 million days yearly. When such loss of

productivity is combined with an increase in health care services associated with the

disorder, the costs of depression become astronomical. According to the National

Institute of Mental Health, economic costs reach approximately $27 billion annually.

Today, depression continues to be a challenging mental health problem that is worthy

o f much attention (Robinson, Wischman, & Del Vento, 1996).

When Emil Kraeplin first described depression in the early 1800’s, it was

characterized as a disease. Today we know that depression is not something

somebody has, but is more a feeling that one experiences for some period of time.

Some o f the common mental states and behaviors that accompany depression include,

but are not limited tor feeling guilty, burdened, and/or dysphoric, problems interacting

with others, low levels of activity, and various physical problems. In order to be

formally diagnosed with Unipolar Depression, as operationalized by Diagnosticthe

and Statistical Manual o fMental Disorders (4th Edition; DSM-IV; American

Psychiatric Association, 1994), an individual must experience a 2-week period of

dysphoric mood or loss of interest or pleasure, and at least four other symptoms that

may include: (a) significant weight loss or gain; (b) appetite disturbance; (c) insomnia

or hypersomnia; (d) psychomotor agitation or retardation; (e) fatigue or loss of

energy; (f) feelings of worthlessness; (g) inappropriate guilt; (h) impaired

concentration; and (0 recurrent suicidal ideas or a suicide attempt.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. These core symptoms of a depressive episode are the same for children,

adults, and die elderly, although every individual who suffers from depression does so

in their own unique way. Furthermore, there are large individual differences as to

which feelings or behaviors accompany the disorder, and the extent to which an

individual experiences these symptoms varies widely from person to person

(Lewinsohn, Munoz, Youngren, & Zeiss, 1978).

Etiological Components o f Unipolar Depression

There have been a number of principles and conceptualizations introduced

over the past century to explain the etiology of depression. One theory that precisely

explains the etiology o f depression, and is backed by numerous years o f empirical

research, is the behavioral conceptualization. Ferster (1966) has put forth one such

theoretical explanation worthy o f discussion. He described several hypothetical

mechanisms by which depression can occur, the first being the assumption that the

major feature of depression is a reduced frequency of adaptive behavior. The

environmental events potentially responsible for this reduction are instances when

excessively large amounts of adaptive behavior are required before reinforcement is

provided or when there is an absence o f reinforcement, aversive stimuli or

punishment, and finally, a sudden change in the environment (e.g., death o f a loved

one). Ferster adds that the common denominator of all the above mechanisms is a

decrease in the rate o f positive reinforcement for adaptive behavior. According to

Lewinsohn, Sullivan,& Grosscup (1980), there are three general reasons why a

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. person may experience low rates o f positive reinforcement. First, the person’s

immediate environment may have few available positive reinforcers. Second, the

person may lack the skills to obtain available positive reinforcers. Finally, the

positive reinforcement potency of events may be reduced.

These changes in the frequency or sources of positive reinforcement can be

viewed as the environmental antecedents o f depressive symptoms and behaviors.

Once these depressive behaviors manifest themselves, they may be maintained by

reinforcement from others (the secondary gain phenomenon), and in turn

strengthened by their consequences (Lewinsohn, Weinstein, & Alper, 1970). For

instance, the individual who mopes around, complains about somatic symptoms, and

agonizes over his or her unhappiness generates reactions from the environment that

may take the form o f sympathy, concern, interest, or suggestions. This positive

attention can then inadvertently reinforce depressive behavior.

Ultimately, as the depressed individual becomes increasingly dysphoric and

depressed, when the opportunity arises to come in contact with positive

reinforcement, inappropriate behavior may surface (e.g., complaining incessantly

about their mood). Close friends and family may then begin to see these individuals

as aversive, thus ignoring future contacts and further decreasing the frequency of

rewards available in the environment. This in turn aggravates the depressed person’s

own self-rejection and selfcriticism, and leads to further isolation. This vicious cycle

may continue until one is so depressed that he or she is resistant to attempts made by

others to help him by showing love and friendship (Bandura, 1977).

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Contrary to the behavioral etiological conceptualization for depression is the

cognitive etiological theory. Whereas the behavioral view states that a depressed

person’s behavior is what causes the following despondent emotion or thought, the

cognitive conceptualization would argue that depressive thoughts or emotions

precede corresponding depressive behavior, and if one can alter negative thoughts or

emotions more positive behavior patterns will follow. Beck’s cognitive theory of

depression (Beck, Rush, Shaw, & Emery, 1979) has been the most thoroughly

researched approach in the cognitive arena (Taylor & Marshall, 1977). Beck’s theory

o f depression focuses on the strong relationship between thinking and depression. In

Beck’s view, a depressed individual consistently thinks he or she is deficient and

inadequate, and life experiences are consistently construed in a negative way. It is

these erroneous beliefs and maladaptive information processing that eventually play a

role in the onset and maintenance of depressive episodes (Kovacs & Beck, 1978).

More specifically, Beck et al. (1979) proposed that there are three concepts

that define the etiological components o f depression. These components include: (1)

the cognitive triad, (2) schemas, and (3) cognitive errors (faulty information

processing). The concept behind the cognitive triad explains that depressed people

typically follow three negative cognitive patterns. First, depressed people regard

themselves in a negative manner. More specifically, they feel defective, inadequate,

diseased, or worthless. Second, depressed people interpret their ongoing life

experiences in a negative way. They believe they cannot attain their goals because

the world makes exorbitant demands on them. Furthermore, interactions with the

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. environment are misinterpreted and the person is left feeling defeated or deprived.

Finally, depressed people see their future in a negative light. Further difficulties are

anticipated, while hardship, frustration, and deprivations are expected to plague them.

The second major element in Beck’s cognitive model o f depression

incorporates the concept of schemas. According to Beck et al. (1979), schemas are

stable cognitive patterns that are used to screen out, differentiate, and code the stimuli

that confront us daily. Experiences thus become categorized and evaluated through a

matrix o f schemas. People suffering from depression are said to possess a dormant

cognitive schema. This schema may then become active under conditions of stress

that are related to experiences initially responsible for embedding the negative

attitude. Once activated, this schema influences the way information is processed and

people lose voluntary control over thinking processes. Other more appropriate

schemas are then unable to be evoked (Kovacs & Beck, 1978; Beck et al., 1979).

The final major element that Beck et al. (1979) recognizes as critical in a

discussion o f cognitive factors o f depression is faulty information processing. The

depressed person perceives their present, future, and outside world (the cognitive

triad) in a negative light. It is these systematic errors in thinking that maintains their

beliefs they are worthless, inadequate, etc. More specifically, depressed people have

a tendency to make broad global statements regarding the events in their lives, and

the meanings they give to these events are “extreme, negative, categorical, absolute,

and judgmental” (Beck et al., 1979, p. 14). The depressed person consequently leads

a biased rendition o f then: life experiences and expects to fail at anything they

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. undertake, all the while engaging in a tremendous amount o f selfcriticism (Beck et

al., 1979).

Behavior Therapy Treatment Modalities

Because both the behavioral and cognitive conceptualizations of depression

have been supported with many years o f clinical and empirical evidence (Beck et al.,

1979; Steinbrueck, Maxwell, & Howard, 1983; Dobson, 1989; McLean, Ogston, &

Grauer, 1973), successful treatment modalities for each have followed. While there

are noted similarities between these two modalities o f treatment (Beck, 1970), each

helps the depressed individual in a unique way. The behavioral treatment of

depression is based primarily on learning theory and its therapeutic goal is to change

the contingencies that initiate and maintain depressive behaviors. According to

Kovacs (1979), the traditional behavioral therapy for depression essentially seeks to

increase the frequency of socially desirable behaviors, while at the same time

decreasing the rate of undesirable ones. Teaching the client the necessary skills that

will enhance the ability to come in contact with positive social reinforcers can do this.

Many successful behavioral interventions have therefore been adopted that have

allowed the behavioral therapist to institute those that are best suited for the

individual client.

Therapeutic techniques that help an individual restore an adequate schedule of

reinforcement by increasing activity levels are both common and instrumental in

decreasing depressive symptoms (Lewinsohn et al., 1980). “Behavioral activation”

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. employs the well-known idea that being active leads to rewards that are antidotes to

depression (Hammen, 1997, p. 142). As noted by Beck et al. (1979), people who are

depressed typically participate in a great deal of social withdrawal and avoidance on

the basis that activity and social interaction are meaningless, not interesting, or that

others see them as a burden. They criticize themselves for their withdrawal and lack

of motivation, which thereby adds to feelings of inadequacy and helplessness. As a

result, remaining inactive becomes part of a vicious cycle that is difficult to break out

of.

One such intervention that decreases a client’s passivity and inactivity

involves the therapist and patient collaborating to construct a daily activity schedule.

Essentially, specific hour-by hour activities are planned throughout the day and the

client monitors and records these completed activities on a record form. Constructing

specific goal-oriented tasks not only shows the client that he or she is capable of

setting and accomplishing goals, but also provides the therapist and client with

concrete data from which to base assessments o f the patient’s functional capacity

(Beck et al., 1979).

To supplement the activity schedule, a “graded task” hierarchy may be

incorporated into the daily plan (Beck et al., 1979, p. 121). Graded task assignments

are stepwise tasks or activities that help clients progress to completing more difficult

assignments as the simpler ones are mastered (Hammen, 1997). After the successful

completion of a task, the patient usually foels motivated to move onto the next step.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Repeated successes generally begin to undermine the feelings o f inadequacy and

worthlessness that fuel one’s inactivity (Beck et al., 1979).

While it is important that a depressed individual remain behaviorally

activated, it is also important for a client to derive some pleasure from these activities

and tasks. According to Beck et al. (1979), some depressed patients engage in

activities, but procure very little pleasure from them. One reason for this may be their

“selective inattention to sensations of pleasure” (Beck et al., 1979, p. 128). Mastery

and Pleasure techniques have thus been designed to drive a patient to undertake a

particular pleasurable activity for a specified number of minutes each day. Changes

in mood and reductions in depressive symptoms associated with the pleasurable

activity are recorded by the patient. More specifically, it is helpful if the patient rates

their degree of Pleasure (P) and Mastery (M), which refers to their sense of

accomplishment when performing a particular task or activity. As a result, these

ratings rivet one’s attention to the enjoyment they are deriving from the participation

in and completion o f activities (Beck et al., 1979).

Interventions that have been aimed at improving depressed patients’ social

and assertive skills are also common in the behavioral therapeutic process. As

mentioned previously, depressed individuals typically have a tendency to slip into

social isolation, becoming increasingly passive as their opportunities to interact

socially become fewer and fewer (Beck et al., 1979). Social skills training seeks to

increase the frequency o f adaptive behaviors associated with positive social

reinforcement. Furthermore, so that depressed individuals can extract more positive

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. reinfbrcers from their lives, assertiveness skills (e.g., role-playing) may also be taught

(Lewinsohn, Antonuccio, Steinmetz, & Ten, 1984).

Cognitive Therapy Treatment Modalities

Along with BT, Cognitive therapy (CT) has also established itself as an

effective short-term therapy for clinical depression (Dobson, 1989). The cognitive

therapy o f depression, developed by Beck and his associates (Beck et al., 1979), is a

specific type o f the broad class o f therapies called cognitive behavioral (Dobson &

Block, 1988). Contrary to the emphasis in behavioral treatment for depression, CT is

based on the premise that introspective data (i.e., thoughts, feelings, wishes,

daydreams, attitudes) provide a wealth of information that the therapist can use as the

principal target for therapeutic work (Beck, 1970). Unlike behavior therapy which

focuses on the overt behaviors o f its clients, CT focuses on a set o f operations that

center around “a client’s cognitions (verbal or pictorial) and on the premises,

assumptions, and attitudes underlying these cognitions” (Beck, 1970, p. 187).

Because a cognitive psychologist believes that dysfunctional thought patterns are

what fuels one’s depressive symptoms, CT focuses to change the client’s

misinterpretations, self-defeating behavior, and dysfunctional attitudes. The client is

taught to identify his or her faulty cognitions and recognize the crucial link between

negative antecedent thoughts and the subsequent negative feelings that follow

(Kovacs & Beck, 1978).

i Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. According to Beck et al. (1979), because this relationship between negative

cognitions and unpleasant emotions is so strong, CT relies heavily on “emotional

techniques” as part o f its therapeutic repertoire (p. 36). The following is a list o f

operations that may be included in CT. While not exhaustive, this slate of

interventions is designed to delineate and test the client’s specific misconceptions and

maladaptive assumptions.

As Beck et al. (1979) notes, the first and most critical intervention involves

the self-monitoring o f “automatic thoughts.” Automatic thoughts come out of the

blue, unprompted by events and are not necessarily the result of ‘directed’ thinking.

These thoughts are typically immediate and are valid in the sense that the individual

accepts them as true without further analyzing them. Automatic thoughts spawn

further thoughts and images to emerge and cause a “downward spiral o f despair”

(Clark & Fairbum, 1997, p. 263). To target these automatic thoughts, the therapist

trains the client to observe, define, and record the negative cognitions. Through in-

between session assignments, the relationship between cognition and affect are

demonstrated, using specific, real-life examples. Once a client leams to detect as

many negative automatic thoughts as possible, the client and therapist can work

together to examine the evidence for and against these distorted automatic thoughts.

With the help o f the therapist, more pragmatic and reality-oriented interpretations for

these biased cognitions can then be substituted. While the depressed person

characteristically views the world in a negative light, the goal here is to encourage a

more accurate description of the way things truly are. Finally, as the client leams to

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. identify, challenge, and alter these dysfunctional beliefs, a decrease in depressive

symptoms may follow (Beck et al., 1979).

While there are obvious differences between the behavioral and cognitive

treatments for depression, these two systems of psychotherapy share many

similarities and are often blurred. First, in both the behavioral and cognitive

paradigms, clients are trained to initiate, conduct and evaluate their own treatment,

with the guidance of their therapist. In essence, both are “action” therapies in which

clientsdo something about their difficulties, rather than justtalk about them.

Furthermore, clients engage in specific tasks to alleviate their depressive symptoms.

These therapeutic tasks (i.e., homework assignments) are an integral part of both BT

and CT and are commonly used to designate therapy procedures in the client’s natural

environment (Spiegler & Guevremont, 1998). In addition, the goals set for both

therapies are specific, as opposed to open-ended, and they guide the treatment process

that will be implemented for that particular therapy (Beck, 1970).

Another similarity is the fact that both cognitive and behavior therapists focus

at least some of their techniques at public, overt symptoms or behavior problems.

While the targets of therapeutic change differ for both behavior and cognitive

therapists, both systems conceptualize symptom formation in terms of constructs that

are accessible to either behavioral observation or to introspection (Beck, 1970).

Moreover, in contrast to psychoanalytic therapy, neither behavior nor

cognitive therapies focus their sessions on recollections or reconstructions o f the

client’s childhood experiences and early family relationships. Causal relationships

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. between childhood events and current psychological functioning are rarely made,

while the focus o f treatment is on the “here and now,” rather than on historical

determinants of behavior. Techniques are employed to change the relevant current

factors that are influencing the depressive symptoms (Beck, 1970; Franks &

Barbrack, 1983; Spiegler & Guevremont, 1998).

A final commonality between behavior and cognitive therapies is that both

paradigms exclude most traditional psychoanalytic assumptions (e.g., infantile

sexuality, the unconscious, defense mechanisms, fixations) from clouding the

therapeutic process. More specifically, both systems essentially restrict the high-level

abstractions that are characteristic of psychoanalytic therapy (Beck, 1970).

The Advent o f Cognitive-Behavioral Therapy

While the theoretical frameworks of behavioral and cognitive therapies are

noticeably congruent on many levels, researchers have merged the two to form

“cognitive-behavioral” therapy (CBT) for depression (e.g., Beck’s Cognitive

Therapy). Essentially, CBT represents an extension of traditional behavior therapy

and encompasses the modification of cognitive events as actual behaviors (Kovacs,

1979). While behavioral and cognitive approaches differ in their emphasis on the

etiological role o f overt and. covert behaviors, when the two systems are united to

form the cognitive-behavioral approach, it is indicated that both covert and overt

behaviors play important roles in maintaining and modifying depression (Taylor &

Marshall, 1977).

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. According to Dobson & Block: (1988), the actual outcomes o f CBT will vary

from client to client, but in general, the two main indices targeted for change are both

cognition and behavior. At its core, CBT shares three key positions: (1) cognitive

activity affects behavior, (2) cognitive activity may be monitored and altered, and (3)

desired behavior change may be affected through cognitive change (Dobson & Block,

1988). Both cognitive and behavioral techniques are exercised in CBT, as the

therapeutic goal is twofold. Therapist and client set out to alter faulty information

processing systems, while simultaneously modifying the environmental contingencies

that maintain depressive symptoms.

While CBT places emphasis on the cognitive mechanisms that create

behavioral effects, Dobson & Block (1988) add that elaborate cognitive mechanisms

are not ultimately required for behavioral change to occur. In fact, some CBT

interventions may have little to do with cognitive appraisals and evaluations, but may

instead be heavily dependent and focused upon client actions and behavior.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. CHAPTER II

REVIEW OF THE LITERATURE

Evidence Supporting Behavior Therapy

While CBT has been widely established as an effective treatment modality, its

components in isolation have also proven to be clinically effective. Numerous studies

have investigated depression treatments with an emphasis on behavioral principles

and interventions and have produced findings that support the use of these techniques.

For instance, in a study conducted by Wilson, Goldin, & Charbonneau-Powis (1983),

a behavioral treatment for depression was found to be clearly superior to no

treatment. Twenty-five depressed, non-psychotic participants were randomly

assigned to either a behavior therapy or a waitlist condition. Behavior therapy was

implemented for eight weeks and included interventions such as activity schedules,

graded task assignments, daily self-monitoring of mood, and social reinforcement for

attempted and completed activities and tasks. Measures o f depressive-related

symptomatology and treatment-related target areas were administered prior to

treatment, at mid-treatment, at the termination of treatment, and at a 5-month follow-

up. In comparison to the waitlist condition, participants in the BT condition

significantly unproved on self-report and clinician rated measures such as the Beck

Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961), with

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. F (l, 22) = 55.04, p < 0.01, and the Hamilton Rating Scale for Depression (HRSD;

Hamilton, 1960), with F (l, 22) = 20.04, p < 0.01. Additionally, treatment effects

were maintained at the 5-month follow-up [F (1,14) = 56.0,p < 0.01]. The results of

this study provided support for the use of short-term behavioral therapy for

depression (Wilson et al., 1983).

Another study that provided support for BT as a viable treatment for

depression was conducted by McLean, et al. (1980). The authors compared social-

skills behavior therapy for couples to a “doctors choice” treatment for 20 depressed

outpatients. According to their findings, the group that received social-skills behavior

therapy demonstrated significant improvement in original target problems as

compared to a “doctor’s choice” of treatment group. The “doctor’s choice” treatment

varied as a function of the treating agency and involved diverse psychological

interventions (e.g., office consultations with a social worker) or pharmacological

interventions (e.g., antidepressant medication). Ten patients received8-week an

behavioral treatment and10 were returned to their referral sources (“doctor’s

choice”). Pretreatment assessment consisted o f self-ratings of mood and the

construction of a list of five problematic target behaviors (e.g., decrease use of

negative verbal interactions). Results showed that at the end of treatment, the

behavioral treatment had a significant positive impact on the target behaviors(p <

0.001), whereas those in the comparison group did not(p < 0.23). Also, compared to

pretreatment levels o f depression, the experimental group showed a significant

decrease in depression levels (r=4.07,p < 0.001), as measured by the Depression

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Adjective Checklist (DACL; Lubin, 1965). The significant difference in depression

levels were also maintained at the time of follow-up (f = 3.42,p < 0.01). This study

yielded further support for the effectiveness o f behavioral techniques in the

management o f depression.

Evidence Supporting Cognitive Therapy

Cognitive therapy has also proven itself efficacious in the literature as a potent

treatment for depression. For instance, Shaw (1977) demonstrated that Beck’s CT

was clearly superior to a no-treatment control group in decreasing depressive

symptomatology. The sample consisted o f 32 mildly to moderately depressed

persons who were treated at a university student health service. A group treatment

format was utilized over four weekly 2-hour sessions. Results indicated that the

cognitive modification group, as compared to the waitlist control group, demonstrated

a significantly greater decrease in self-report depressive symptomatology on the BDI

(t = 4.47, p < 0.01) and on clinical ratings o f the HRSD(t — 2.79, p < 0.01). These

results provided favorable and supporting results for a cognitive treatment program

for depression.

In a study conducted by Rush, Beck, Kovacs, and Hollon (1977) CT was

again established as a promising treatment for depression, as 79.8% of patients

showed marked improvement or complete remission of symptoms. Nineteen

moderate to severely depressed outpatients received a maximum o20 f sessions of

CT, while 22 participants (also experiencing moderate to severe depression) received

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. weekly 20-minute medication reviews and nonspecific supportive therapy. Both

psychological and pharmacological treatments (i.e., Tricyclics) were administered for

12 weeks and assessments included a variety o f self-rating scales including the Beck

Depression Inventory and independent clinical ratings such as the HRSD and the

Raskin Depression Scale (Raskin, Schulterbrandt, Reating, & McKeon, 1970).

Results showed that not only was CT associated with a significant decrease in

depressive symptomatology on the BDI [r (17) = 11.76, p < 0.001], but it resulted in

greater clinical improvement on the HRSD [/ (14) = 7.78,p < 0.001] and the Raskin

Depression Scale [t (13) = 9.50, p < 0.001]. Additionally, a one-way analysis of

covariance for treatment effects unveiled cognitive therapy as significantly more

effective than pharmacotherapy in reducing depressive symptomatology, withF

(1,29) = 4.43, p < 0.05 (Kovacs, 1979; Rush et al., 1977).

Finally, in a meta-analysis conducted by Dobson (1989), an exhaustive review

of 28 studies was completed to analyze the effect of Beck’s CT on depressed clients.

The clinical efficacy o f CT was compared against a waitlist or no-treatment control,

pharmacotherapy, behavior therapy, and other various psychotherapies (e.g.,

psychoanalysis, interpersonal therapy). The results of this meta-analysis showed that

CT was more effective than nothing at all, behavior therapy, and pharmacotherapy.

More specifically, the average CT client did better than 98% of control subjects, 67%

better than behavior therapy clients, and 70% better than drug therapy or other

psychotherapy clients.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Evidence for Combined Treatment-Medication Plus Cognitive Therapy

As noted by Hollon, et al. (1992), numerous questions remain regarding the

efficacy of CT relative to pharmacotherapy in the treatment of depression.

Consequently, numerous studies have been conducted that examined the combined

effects of CT and pharmacotherapy in comparison to each modality in isolation (for a

comprehensive review, see Hollon, Shelton, & Loosen, 1991). The literature seems

to be divided in that some studies favor the combined modality o f cognitive

pharmacology over either treatment alone (Bowers, 1990), while others have found

no significant differences between combined treatment and CT or pharmacotherapy

alone (Murphy, Simons, Wetzel, & Lustman, 1984; Hollon, Shelton, & Davis, 1993;

Oei&Yeoh, 1999).

A recent study reported a significant benefit for combined treatment in a

multicenter study of patients suffering from chronic, nonpsychotic major depression

(Keller, et al., 2000). The sample consisted o f 681 adult outpatients who were

randomly assigned to (a) cognitive-behavioral therapy, (b) nefazodone, or (c) a

combination o f the two. All treatments were administered for 12—16 weeks and the

primary outcome measure was the Hamilton Rating Scale for Depression (HRSD;

Hamilton, I960). Remission was defined a priori as an HRSD score of no more than

8 at weeks 10 and 12. Although participants in all three groups significantly

improved over the 12 weeks (p < 0.001), an analysis o f endpoint HRSD scores

revealed that from week 4 through 12, the average rate o f improvement in the

combined-treatment group was significantly larger than the rate o f improvement in

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. the nefazodone and psychotherapy groupsip < 0.001). More specifically, 85% of

participants in the combined-treatment group had a positive response to treatment by

week 12, as compared with 55% of participants in the nefazodone group and 52% in

the psychotherapy group ip < 0.001 for both comparisons). Because the combined

treatment group achieved early benefits from medication and then additive benefits

from psychotherapy later in the trial, the authors suggested that the combination of

two independent effects rather than a synergistic mode o f action, increased patients

response to treatment. In sum, the authors determined that the degree of superiority

o f combination therapy provided a clinically meaningful advantage over both CT and

medication alone.

One study that attested to the additive effects o f combined cognitive

pharmacotherapy was conducted by Blackburn, et al. (1981). Sixty-four clinically

depressed patients, drawn from a general practice setting and a hospital outpatient

clinic, were randomly assigned 20to weeks of treatment in one of three conditions:

(a) cognitive therapy, (b) tricyclic pharmacotherapy, or (c) a combination o f the two.

Depressive symptomatology was assessed via the BDI, HRSD, and the Snaith’s

Irritability, Depression, and Anxiety Scale (IDA; Snaith, Constantopoulos, Jardine, &

McGuffin, 1978). For the outcome results, Snaith’s scale displayed few overall

changes, but the BDI and HRSD both revealed clear cut effects. Results revealed that

in the hospital outpatient sample, the combined treatment o f CT and tricyclics was

significantly superior to CT or pharmacotherapy aloneip < 0.01). In the general

practice setting however, the combination treatment and CT alone were equally

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. effective and considerably better than drugs alone (Blackburn et al., 1981), Not only

did this study have implications for establishing appropriate treatments for

depression, but it also was the first outcome study to use a population that was not

from North America. Previous to this study, the generalizability of the effectiveness

of CBT across continents was in question, but using a European sample served to

decrease existing suspicions (Williams, 1992).

In contrast, studies have not found any significant advantage for the combined

modality relative to either modality alone. Murphy et al. (1984) compared the

differential effects of CT, pharmacotherapy, CT plus a placebo, and CT plus

pharmacotherapy by randomly assigning eighty-seven moderately to severely

depressed psychiatric outpatients to one of four conditions. Each participant

completed 12 weeks of treatment and was assessed with a self-report measure (i.e.,

the BDI) and an independent clinical interview (i.e., the HRSD). Results prompted

the authors to conclude that overtime, while all three treatment groups led to

significant decreases in depressive symptomatology [F (2,65) = 236.50,p < 0.001],

improvement did not differ as a function of the different treatment modalities6, [F (

130) = 0.32, p = 0.92]. In essence, combining treatments did not lead either to

additive effects or negative interactions (Murphy et al., 1984).

In a more recent randomized clinical trial, Blackburn & Moore (1997) also

found that combining CT and medication was not significantly more effective in

lowering depression levels than either treatment alone. Seventy-five outpatients with

recurrent major depression were allocated to three groups, each including 16 weeks of

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. acute treatment and two years’ maintenance therapy, in the following manner: (a)

antidepressants and maintenance antidepressants, (b) CT and maintenance CT, or (c)

a combination of antidepressants and maintenance CT. Ratings on outcome measures

(i.e., BDI-n and HRSD) were repeated every four weeks during acute treatment and

every four months during the 2-year follow-up phase. Results for acute treatment

showed that over the 16-week treatment period, all three treatment groups continued

to improve over time and there was no significant difference among treatments on

both the HRSD and the BDI-II(p < 0.0001 for both measures). Results o f longer

term outcomes indicated that patients in all groups continued to improve significantly

over time [F (6,329) = 4.51, p < 0.001] and there were no significant differences

between treatments [F(2,55) = 0.31,/? = ns] at any point in time. Thus, this result

supported the idea that combining acute medication and maintenance CT treatments

was not more effective in lowering depression levels than either treatment modality

alone. Further analyses did show one trend for a difference appearing at 20 months

on the BDI [F (12,329) = 1.61,/? < 0.08], reflecting a more steady improvement in

the two maintenance CT groups. This allowed Blackburn and Moore (1997) to

conclude that “maintenance cognitive therapy has a similar prophylactic effect to

maintenance medication and is a viable option for maintenance after acute treatment

with medication in recurrent depression” (p. 328).

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Combined Cognitive and Behavior Therapy

Not only have the behavioral and cognitive therapies been tested for clinical

efficacy, but a variety of studies have also supported cognitive-behavioral treatments

for depression. One such study (Taylor and Marshall, 1977) noted that, because both

covert and overt events play important roles in maintaining and modifying

depression, the additive effects of behavior and cognitive therapies (i.e., CBT) may be

therapeutically more effective in decreasing depressive symptomatology than either

modality alone. The authors tested this hypothesis by randomly assigning 28 mild to

moderately depressed college student volunteers to one of four groups:1) (cognitive

treatment, (2) behavior treatment, (3) cognitive and behavioral treatments combined,

or (4) waitlist control group. Behavior therapy encompassed the approaches of

Ferster, Lazarus, and Lewinsohn, while CT encompassed a combination o f modalities

offered by Beck, Ellis, Bandura, and Marston (Kovacs, 1979). Each experimental

participant received six 40-minute treatment sessions. Depression outcome measures

included the BDI, the D-30 scale (Dempsey, 1964), and the Visual Analogue Scale

(VAS; Aitken, 1969). Results showed that while there were significant

improvements in self-rated symptomatology for all three treatment groups, the

combined cognitive-behavioral treatment was more effective in decreasing depressive

symptoms [F (1,18) = 6.71 ,p < 0.03) than either behavioral or cognitive treatments

alone. These effects were maintained at the 5-week follow-up point [F (1 ,18) = 9.64,

p < 0.01]. In their attempt to examine the utility o f CBT, Taylor and Marshall (1977)

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. concluded that for maximum benefit, the integration o f BT and CT (i.e., CBT) should

be performed when treating depression.

Dismantling of Cognitive Behavior Treatment

While the clinical effectiveness of CBT has been well-documented (Dobson,

1989; Miller & Berman, 1983; Taylor & Marshall, 1977; Williams, 1992), a question

remains as to which component of CBT is most responsible for therapeutic change

and improvement. Is it the behavioral component, the cognitive component, or the

additive effects of the two that make CBT so clinically effective? There is an evident

need to dismantle CBT in order to identify the components that are either sufficient or

vital ingredients for improving depressive symptomatology.

An ingenious study conducted by Jacobson, Traux, Addis, Koemer, GoIIan,

Gortner, & Prince (1996) set out to answer these questions by dissecting Beck’s CT

for depression (Beck et al., 1979). Jacobson and his colleagues randomly assigned

152 depressed outpatients to one o f three treatments based on components of CBT:

(1) behavioral activation (BA), which is the behavioral component o f CBT; (2)

automatic thoughts (AT), which includes behavioral activation along with skills to

modify automatic thoughts or; (3) “full” CBT, which consists ofbehavioral

activation, modification o f negative thoughts, plus changing core dysfunctional

schemas. It was hypothesized that “CT should work significantly better than AT,

which in turn, should work significantly better than BA” (p. 296). An additional

purpose for this study was to investigate whether the various treatments differentially

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. affected the process that they were supposed to affect. For instance, was the “full”

CBT more successful at modifying dysfunctional schemas than BA? Would the BA

condition be more successful at activating people to participate in previously

enjoyable activities than the full CBT?

Participants in each condition received treatment for 16 weeks with a

maximum o f 24 sessions. The depressive symptomatology was measured for all

participants with the Longitudinal Interval Follow-up Evaluation-II (LIFE; Keller, et

al., 1987), the BDI and the HRSD. Measurements were taken before therapy, at the

time o f termination, and at6,12, and 24-month follow-ups. Unexpectedly, results

showed that after20 sessions, as well as at the6 -month follow-up, there were no

significant differences in self-reported depression levels between the three groups.

Additionally, there were no differences found between the treatments one or two

years after treatment (Gortner, Gollan, Jacobson, & Dobson, 1998).

In opposition to their hypothesis, those who received BA alone fared as well

as those who were taught additional coping skills to counter depressive thinking.

Essentially, the BA component was as successful in reducing depression and altering

negative thinking and attributional styles as was the AT and “full” CBT conditions.

Most importantly, this study identified the BA condition as an active ingredient in

CBT, capable o f producing clinically significant antidepressant effects. In sum,

Jacobson and his colleagues found no evidence that CBT was any more effective than

either o f its components alone (Jacobson et al., 1996). In other words, as noted by

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Martell, Addis, & Jacobson (2001), helping to activate these participants was just as

effective to treat their depression as helping them to change their thinking.

These results have important implications for the treatment outcome o f major

depression, as they run contrary to the cognitive model o f depression put forth by

Beck and his colleagues (Beck et al., 1979), that states that the modification of

negative cognitions are necessary to maximize treatment outcome. The Jacobson et

al. (1996) study calls into question some of the assumptions o f the cognitive-

behavioral model by suggesting that altering thinking and dysfunctional schemas may

not be necessary to counter depressive symptomatology. Alternatively, it is

suggested that the participation in and exposure to a variety of pleasurable activities

served not only to change dysfunctional thinking, but to act as an antidote for

depression (Hammen, 1997).

In the search for empirically validated treatments that are short-term, cost-

effective and simpler to leam and administer, the Jacobson et al. (1996) findings may

have great economic and clinical value. Having to implement only the BA portion of

CBT makes behavioral activation appear much more parsimonious and “user

friendly” (Robinson et al., 1996). As noted by Chambless and Hollon (1998), the

behavioral approaches to depression are typically easier to master than the more

complex cognitive interventions. In turn, this could make BA more accessible to less

experienced orparaprofessional therapists. Furthermore, BA represents a less

expensive alternative to CBT in that the intervention choices are fewer and therapists

do not have to implement the foil CBT treatment plan (Jacobson et al., 1996).

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Problem Statement

Previous research suggests that cognitive behavioral treatment of depression

stands as the psychotherapeutic intervention o f choice in the treatment of clinical

depression (Hammen, 1997). Recent work by Jacobson et al. (1996) further suggests

that the active ingredient in cognitive behavioral treatment of depression might entail

behavioral activation. This ingredient is found in the overall cognitive behavioral

treatment protocol as one of three clearly identifiable components. According to the

Jacobson investigation behavioral activation may be simpler to administer and yet

achieve outcomes that equal those found with the full cognitive behavioral treatment

protocol. If this observation can be verified it would serve to render a more efficient

treatment for clinical depression. It would also give rise to a conceptual challenge to

the prevailing theory of cognitive behavioral intervention; a theory that suggests that

direct modification of dysfunctional cognitions is essential for successful treatment

outcome.

The present investigation aims to conduct a quasi-replication of the basic

findings noted in the Jacobson study. It will utilize a sample that differs, however,

from that treated by Jacobson. In the practice setting in which most psychologists

operate, clients present for treatment even while still consuming psychotropic

medications. Of all the people who are prescribed a psychotropic medication by a

psychiatrist, as many as one-quarter to one third (30.4%) are treated with

antidepressant medication (Olfson & Klerman, 1993). It is policy in many

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. community agencies that clients who are diagnosed as clinically depressed and who

receive antidepressant medication must also be seen by an additional psychosocial

intervention service. These other psychosocial interventions may include

psychotherapy, case management, orpsychoeducational services (personal

communication 1998, Venture Behavioral Health).

Because o f this prevailing reality, it is important to test the effectiveness of

behavioral activation with clients who realistically present while consuming

medication, in addition to testing clients who are unmedicated, as was done in the

Jacobson study. Yet this must be done in a way that allows for reasonably valid

comparisons between persons who were and were not medicated. This arrangement

is made difficult in the present study by the absence o f a psychiatrist who would

simultaneously administer medication or no medication within the context of the

proposed research design. However, the present investigation will attempt to achieve

quasi-experimental control that permits reasonable inferences regarding the effects of

behavioral activation treatment of both samples. The primary research question is

“What are the effects o f behavioral activation on a mixed sample o f medicated and

unmedicated depressed adults?” hi answering this question, this study will provide

further clarification on the role of behavioral activation protocol in the treatment of a

more “real world” sample of depressed clients.

In this investigation, rather than random assignment to one or the other

medication condition, all subjects, irrespective o f medication condition will be

randomly assigned to either a waitlist (delayed treatment) control or an. immediate

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. treatment condition. Those subjects who are medicated, however, will have to have

initiated medication at least four weeks prior to entering the study and must remain on

the same medication for the duration of the study period. Changes in doses will be

allowed. This arrangement is essential in order to provide a fair test o f whether any

treatment outcomes are attributable to the medication condition alone. If subjects in

the delayed treatment condition continue to qualify for admission into the study even

though they continue to take medications for a period o f at least six weeks, then it is

unlikely that observed treatment outcomes can be easily attributable to medications

alone. This would suggest that behavioral activation was at least a contributing factor

to treatment outcome.

On the other hand, if unmedicated subjects who receive immediate treatment

demonstrate positive outcomes at post-treatment, when compared to the unmedicated

subjects in the delayed treatment condition, then it must be concluded that behavioral

activation was likely responsible for the observed outcomes. However, because of

the quasi-experimental nature o f this investigation, no firm conclusions regarding

causality can be drawn. That level o f conclusion will be left to a future true

randomized controlled trial.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. CHAPTER III

METHOD

Sample

Seventeen adult participants seeking mental health services for Unipolar

Depression were recruited from the Kalamazoo and Southwestern Michigan regions

through public service announcements, newspaper advertisement, solicitations from

community professionals, and other healthcare agencies.

All participants met criteria for Major Depressive Disorder (MDD) according

to the Diagnostic and Statistical Manual o f Mental Disorders (4th edition; DSM-IV;

American Psychiatric Association, 1994). The DSM-IV diagnosis was based on the

Structured Clinical Interview forDSM-IV-Non Patient (SCID-NP; First, Spitzer,

Gibon, & Williams, 1997). Participants scored at least 20 on the Beck Depression

Inventory-II (BDI-H; Beck, Steer, & Brown, 1996), and 14 or greater on the Revised

Hamilton Rating Scale for Depression (RHRSD; Warren, 1996). The author and a

licensed clinical psychologist who had utilized both outcomes in several other

investigations provided training and supervision o f the RHRSD and SCID-NP.

Exclusion criteria included a number o f coexistent psychiatric disorders

including bipolar or psychotic subtypes of depression, panic disorder, current alcohol

or other substance abuse, past or present schizophrenia or schizophreniform disorder,

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. organic brain syndrome, obsessive compulsive disorder and mental retardation.

Additionally, the comorbid presence of personality disorders were limited inasmuch

as the percentage of patients with a personality disorder in the sample approximated

the percentage of patients in the population o f Psychology Clinic patients having the

same personality disorder.

Furthermore, suicidality was assessed and participants who presented a

considerable risk were referred for service outside of the study for further assessment

and determination of appropriateness for participation in the study. A licensed

clinical psychologist, along with the author, made final decisions regarding the

eligibility of the participants. Suicide risk was determined by an individual’s

responses to the suicide items on the BDI-II, the RHRSD, and the SCID-NP, as well

as by any verbalizations o f suicidal ideations made by the patient during the

assessment phase of the study. Finally, participants who were in some concurrent

form o f psychotherapy or who needed to be hospitalized because of imminent suicide

potential or psychosis were deemed ineligible for the study and referred for

alternative treatment.

Setting

All assessment and treatment sessions were conducted in private therapy

rooms at Western Michigan University’s Psychology Clinic, located at 1000 Oakland

Drive, Kalamazoo, MI. Each room was equipped with a one-way mirror so that the

integrity o f the treatment could be monitored with video cameras.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Assessors and Therapists

Second and third year doctoral students in a clinical or counseling psychology

graduate program conducted all assessment interviews. Training and supervision of

the assessment tools were provided by the author and included SCID training videos

and the BDI-II and RHRSD manuals.

Therapists were selected and trained from among third year doctoral students

in clinical and counseling psychology graduate programs. All therapists had at least

two years practicum experience. Therapists received basic training in the cognitive

behavioral treatment of depression and for purposes of the present investigation

received an additional 12 hours of training in the use of Behavioral Activation (BA)

therapy. All therapy training was conducted by the principal investigator, Richard

Spates, Ph.D., who is a licensed clinical psychologist and has vast experience in

cognitive behavioral therapy, along with the author, who at the time o f training had

three years practicum experience and held a temporary license to practice in the state

of Michigan.

Treatments

The treatment implemented in this study was the “behavioral activation”

component of Beck’s Cognitive Therapy (CT; Beck et al., 1979). Behavioral

Activation therapy is based on the behavioral conceptualization that depression is best

understood as “a series o f actions and events rather than some sort of internal object

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. or mechanism” (Martell et al., 2001, p. 12) and results from changes in client’s life

circumstances (e.g., death o f significant other, losing a job). The loss of

reinforcement resulting from these life changes is what precipitates the depression.

Once an individual is depressed, the negative way in which he or she responds to their

environment (e.g., avoidance) often exacerbates their dysphoric mood by depriving

them o f further reinforcement. Thus the purpose of BA is to activate clients so that

they may break a passive approach to life and maximize their opportunity to make

contact with natural, positive reinforcers in their environment (Martell et al., 2001).

The emphasis o f BA is on “focused activation,” as opposed to simply activity at

random. This includes not only finding behaviors and activities that will be positively

reinforcing, but paying close attention to the activities with which one is participating

(e.g., noticing colors, noises, and smells associated with the activity). This attention

to the experience intervention is very similar to the mindfulness training taught by

Marsha Linehan in Dialectical Behavior Therapy (Jacobson, Martell, & Dimidjian,

2001; Linehan, 1993).

Behavioral Activation treatment is a therapeutic tool whose goals are to (a)

determine the life circumstances that precipitate the depression, (b) determine the

coping patterns that maintain and exacerbate the depression (e.g., chronic negativity,

social withdrawal), and (c) develop a treatment plan for improving the coping

patterns and provide access to more reinforcing life circumstances (Jacobson, et al.,

1997). The BA therapist helps the client to achieve these goals by working with them

as a so-called “personal trainer” who helps them to learn and implement a set of skills

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. that are likely to be effective, just as a supportive coach might do. The therapy is

delivered in a directive manner, but the client and therapist choose the direction in

concert. It is important to note that the therapist coaches the client to learn a core set

of BA skills, but because the skills’ form varies from client to client, the BA therapist

is required to be flexible, proficient, and able to coach a wide range o f unique clients.

Without such a supportive, collaborative working relationship, it is unlikely clients

will change ingrained patterns of maladaptive behavior (Martell et al., 2001) and meet

the BA treatment goals.

What BA is not about is teaching clients simple maneuvers that increase

pleasant activities. Many people engage in regular, positive activity and are still

depressed. Therefore, pleasant events in and of themselves cannot be assumed as

antidepressants (Dobson & Joflfe, 1986). As noted by Martell et al. (2001), BA is not

about getting people to do nice or fun things. It is about incorporating directed

activity into a client’s narrow repertoire of behavior, regardless of how one feels

internally, so that they break avoidance patterns and increase the possibility of

coming in contact with reinforcers in their environment.

Behavioral Activation is also not a “psychotherapy from the neck down”

(Martell et al., 2001, p. 64). Therapists who treat clients with BA recognize that not

only are inactivity, withdrawal, and avoidance commonplace depressive behaviors,

but according to Nolen-Hoeksema, Morrow, & Fredrickson (1993), a great deal of

time is also spent thinking about, or ruminating, the misery o f their lives. Thus the

context o f client thinking is assessed and acknowledged, rather than the actual content

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. of the thought. For instance, if a client presents with the ruminative thought,

“everyone at school hates me,” the BA therapist would ask the client under what

conditions does this sort of thinking occur, what is he doing when thinking that way,

and what is he avoiding by spending time ruminating? The client is then encouraged

to identify antecedents and consequences o f such ruminations. Moreover, the

veracity o f that thought would not be challenged or evaluated, but rather the impact of

the behavior “thinking that people hate me” would be addressed (Martell et al., 2001).

The theory and practice o f BA is based primarily upon a manual called

Cognitive & Behavioral Treatment o fDepression: A Research Treatment Manual,

developed by Jacobson and colleagues (Jacobson et al., 1997). This training manual

was derived from Beck’s original cognitive therapy manual, calledCognitive Therapy

o f Depression (Beck, et al., 1979). The BA treatment manual used in this study

contains a total of 25 prescribed assessment and intervention techniques that

therapists can use with their clients. Specific assessment techniques include, but are

not limited to, conducting functional analyses, symptom reports from the BDI-II, and

daily activity schedules. Specific intervention techniques that BA therapists are

permitted to use include, but are not limited to, assigning activities to increase a sense

o f mastery or pleasure, graded task assignments, examining alternative behaviors in

different situations, therapist modeling o f activation strategies, and teaching clients to

give themselves rewards for behavioral achievements. The manual also lists those

interventions that should not be included in treatment (i.e., cognitive interventions).

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Ia sum, over the course o f treatment, therapists administering BA teach clients

a series o f interventions that not only help determine the life circumstances that may

have precipitated the depression, but also identify the coping patterns that most likely

exacerbated the depression. Ultimately the therapist helps the client decrease

avoidance behaviors that maintain the disorder, while teaching the client new coping

patterns that provide access to more rewarding life circumstances.

Treatment Integrity

In order to insure that BA was administered properly, protocol outlines were

supplied to each therapist for each session after initial training. These outlines

described essential steps in the procedure. The particular treatment adherence

measure used in this study (Appendix A) was a modified version of the National

Institute o f Mental Health Collaborative Study Psychotherapy Rating Scale (CSPRS;

Hollon, Evans, Elkin,& Lowery, 1984) that included the procedural steps in BA,

along with a checklist of prescribed BA techniques. Also included was a list of

proscribed cognitive therapy techniques.

Trained observers then viewed a random sample of the video taped treatment

sessions (11%), checking off the presence o f each step in the outline, along with the

specific treatment interventions used that session. Furthermore, inter-rater reliability

checks were performed on this same sample of videotapes. It is also important to

note that the therapists participation in ongoing research team meetings specific to

this investigation likely reduced therapist drift

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Outcome Measures

Depression levels were evaluated for each participant before treatment began,

weekly during the course of treatment, at the termination o f treatment, and at three

months following the cessation o f treatment. The BDI-II (Beck et al., 1996), the

RHRSD (Warren, 1996) and the SCID-NP (First et al., 1997) were the three

inventories used to measure depression levels in all participants. The BDI-II was

completed at the intake session for both the waitlist and treatment conditions. Those

in the waitlist condition only were assessed with the BDI-H at the beginning, middle,

and end (i.e., every other week) o f their six-week delay period. Once the wait period

ended, participants in both conditions completed the BDI-II at the same weekly

intervals over the course of treatment to monitor weekly changes in symptom

severity. Participants in the treatment and waitlist conditions were also given the

BDI-H at post-test and at the 3-month follow-up. In order to assess for the presence

o f Major Depressive Disorder, the SCID-NP was administered at pretest, post-test,

and at the 3-month follow-up for both the treatment and waitlist conditions, while the

RHRSD was completed by the therapist at those same points for both groups.

Known as one o f the most widely used instruments to assess for depression,

the Beck Depression Inventory (BDI; Beck et al., 1961) focuses on evaluation in both

psychiatric and nonpsychiatric populations (Beck, Steer, & Garbin, 1988). According

to Beck, et al. (1961), the BDI was derived from clinical observations about attitudes

and symptoms displayed frequently by depressed psychiatric patients and

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. infrequently by nondepressed psychiatric patients, hi order to correspond more

closely with the diagnostic criteria for major depression in the DSM-IV, the BDI has

been upgraded to the BDI-H (Steer, Ball, Ranieri, & Beck, 1997). Not unlike the

original BDI, the BDI-II contains 21 items that measure 21 symptoms o f depression.

A four-point Likert-type scale, ranging from 0 to 3 is utilized for each item. The

BDI-II measures depressive symptomatology during the two preceding weeks, unlike

the original BDI that measured symptoms for the previous week only. Summingthe

ratings for the 21 items scores the BDI-II. The final score can then be converted to a

depression rating and the guidelines for such ratings are as follows: 0-13, minimal

depression; 14-19, mild depression; 20-28, moderate depression; 29-63, severe

depression.

The BDI-H has demonstrated clinical utility and reliable psychometric

characteristics across a broad spectrum of both clinical and nonclinical populations

(Beck et al., 1996). According to Beck et al. (1996), the BDI-II had an alpha

reliability coefficient of 0.92 when administered to a sample o f500 outpatients from

four different psychiatric clinics. Beck et al. (1996) also confirmed the test-retest

reliability by administering the BDI-H to 26 outpatients. Participants completed the

BDI-H before their first therapy session and a week later, before their second therapy

session. Similar results were reported for both administrations (r = 0.93,p < 0.001).

To provide construct validity for the BDI-II, Steer et al. (1997) administered

both the BDI-II and the Symptom CheckIist-90-R (SCL-90-R), an inventory often

employed for assessing self-reported depression and anxiety (Derogotis, 1983) to 210

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. adult outpatients being evaluated for psychiatric problems. The results confirmed the

construct validity of the BDI-H as the self-ratings on the BDI-II were more positively

correlated with the scores on the Depression subscale than they were with the scores

on the Anxiety subscale of the SCL-90-R (Hotelling 207T = 8.40, p < 0.001). In the

same study, the internal consistency for the BDI-II was also established as the mean

total score on the BDI-H was 24.4 (SD = 13.3) and the coefficient alpha was 0.92.

According to Steer et al. (1997), this represents high internal consistency, as the

sample was moderately depressed according to the diagnostic ranges presented by

Beck et al. (1996). Finally, in order to attest to the convergent validity o f the BDI-II,

Beck et al. (1996) compared the BDI-II to the HRSD (Hamilton, 1960) and also to the

Hamilton Rating Scale for Anxiety (HARS; Hamilton, 1959). Findings presented the

BDI-H as more positively correlated with the HRSD (r = 0.71) than with the HARS (r

= 0.47).

Developed in the late 1950’s, the HDRS is a widely used standardized

interview to measure the index of severity of depressive symptoms. Because the

HDRS is not intended to be a diagnostic measure, it is best completed following a

clinical interview. There have been two modifications to the HSRD since the original

version and it is now referred to as the Revised Hamilton Rating Scale for Depression

(RHRSD; Katz, Shaw, Vallis, and Kaiser, 1995). The revised version o f the HDRS

now consists o f22 items and contains descriptive anchor points for each of the values

for each item. Furthermore, “cognitive” items assessing hopelessness, helplessness,

and worthlessness have been added. These items serve only as descriptors and are

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. not included in the total score for severity. O f the 17 scorable items, nine are rated on

5-point scales (0-4), and8 on 3-point scales (0-2). Total scores range from 0 to 52.

Scores on the RHRSD of6 or below are considered to reflect normal, nondepressed

functioning levels; scores of 7—17 are considered to reflect mild depression; scores of

18-24 reflect moderate depression; and scores of 25 or more are considered to reflect

severe depression (Katz etal., 1995).

As slight modifications were made to the HRSD to develop the RHRSD, the

strong psychometric properties o f the former were not compromised (Katz et al.,

1995). Thus the reliability and validity coefficients for the HRSD will be reported.

In a study conducted to test the reliability and validity o f the HRSD (Riskind, Beck,

Brown, & Steer, 1987), 120 psychiatric outpatients were administered both the HRSD

and the HARS. Results indicated the Chronbach alpha coefficient for the HRSD to

be 0.73, while the average item-total correlation was 0.47, indicating satisfactory

internal consistency (Riskind et al., 1987). As noted by Katz et al. (1995), data on the

interrater reliability of the HRSD are impressive. In a study conducted by Hedlung

and Vteweg (1979), a systematic search was executed to locate all available research

reported on the HRSD from 1967 to 1979. O f the nine studies reviewed, the

interrater reliability coefficient was 0.84 or above. In addition, Ziegler, Meyer,

Rosen, & Biggs (1978) examined the interrater reliability o f the HRSD. Ratings were

made from a videotape o f an interview conducted by psychiatric residents and

compared to the actual interview ratings made by experienced psychologists.

Videotaped ratings correlated 0.97 with the actual interview ratings.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. The final inventory utilized in this study was the SCID-NP (First et al., 1997).

This is a semi-structured interview adminisered by a trained clinician that assesses 33

of the more frequently diagnosed DSM-IV disorders in adults. The SCID-NP is

designed for use in studies in which participants are not identified as psychiatric

patients, such as family studies and research conducted in medical settings (Spitzer et

al., 1992).

The basic structure of the SCID-NP interview is as follows. First, basic

demographic information is obtained. This is followed by questions that elicit the

primary complaint, history of present and past periods of psychiatric disturbance, and

treatment history. To end the interview, the clinician asks general questions about

current functioning, including mood, physical health, use of medications, and social

functioning. A decision tree approach is utilized to test the clinician’s diagnostic

hypotheses (Spitzer et al., 1992).

The SCID-NP was initially used in this investigation at intake to select the

study population of interest and ensure that all participants met the conditions that

were necessary for a DSM-IV diagnosis of major depression. Furthermore, it ensured

that participants did not meet certain DSM-IV diagnoses that would deem them

ineligible for the study. The SCID-NP was then employed at post-test and at the 3-

month follow-up for both conditions to assess for major DSM-IV diagnoses and

documentation of those criteria that were met.

The psychometric data on the SCID confirms it to be a reliable structured

interview. In a large-scale study using 592 participants (Williams et al., 1992), the

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. test-retest reliability of the SCID was examined. This study included randomly

matched pairs o f two professionals who independently evaluated and rated the same

subject within a 2-week period. Combining all disorders on the SCID yielded a

weighted Kappa of 0.61 for current disorders and 0.68 for lifetime disorders.

According to Williams et al. (1992), these values are comparable to those obtained

with other structured diagnostic instruments.

While the reliability o f the SCID has been empirically established in

numerous studies (Segal, Hersen, & Van Hasselt, 1994), there has been little effort to

evaluate its validity (Malgady, Rogler, & Tyron, 1992). In fact, as noted by Kranzler

et al. (1996), prior to the execution o f their validity study on the SCID, they found no

published reports assessing the validity o f the SCID. To validate SCID diagnoses,

Kranzler et al. (1996) divided a sample of 100 substance abuse patients into

subgroups based on the presence or absence of SCID diagnoses o f different substance

use disorders and comorbid conditions. These subgroups were compared on scores

from interviews and questionnaires administered at the time of treatment and six

months after discharge from treatment.

The authors first found support for the concurrent validity of the alcohol

abuse/dependence diagnosis when, as expected, those patients diagnosed with the

disorder had a more extensive family history of alcoholism compared with patients

who had never met criteria for alcoholism (F = 1 0 .7 ,< 0.001). Excellent

discriminant validity for both current (F = 29.14,p < 0.001) and lifetime (F = 22.43,

p < 0.001) alcohol and drug abuse/dependence was also established for this sample.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. As predicted, alcohol-related problems were less prevalent in drug-dependent patients

who were not also alcoholic. Additionally, fewer drug-related problems were exuded

in alcoholic patients who were also not drug dependent (Kranzler et al., 1996).

Procedure

Adult participants seeking mental health services for major depression were

recruited for this study. Recruitment materials included the use of newspaper

advertisements, public service announcements, public postings, and solicitation from

community professionals and other healthcare agencies.

Interested individuals contacted the Anxiety Disorders research group’s

telephone line and left a message requesting to participate in the study. All those

interested were called back and an initial telephone screening was conducted

(Appendix B). During this screening, the nature o f the study was explained and

individuals were assessed for depression symptoms. In addition, individuals were

asked if they were currently using any psychotropic medication or currently enrolled

and participating in psychotherapy of any sort. People who were not experiencing

symptoms o f depression, who had been taking prescription medication for their

depression for less than six weeks, and/or who were currently in other psychological

treatments were deemed ineligible for participation. Appropriate referrals for mental

health services were offered to all ineligible callers.

Eligible individuals were then invited to participate in a second

intake/assessment session held at the Psychology Clinic. Prior to the completion of

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. any outcome measures, individuals were presented with two consent forms

(Appendix C) explaining the nature o f the study and guaranteeing their

confidentiality. Answers to any questions regarding the study were then provided.

Individuals were then asked to sign the consent forms indicating their approval for

participation. One consent form was returned to the assessor while the individual

kept the second for their records.

The next step of this intake involved individuals’ completing a brief

demographic questionnaire (Appendix D). The BDI-II (Appendix E) was then

completed and if a score of at least 20 was obtained, individuals were subsequently

interviewed with the SCID-NP (available upon request). If a diagnosis of major

depression was obtained and other disorders that would deem a person ineligible were

ruled out, individuals were thanked for their time and told they would be notified

within one week regarding their eligibility in the study. Finally, assessors completed

the RHRSD (Appendix F) and if a score of at least 14 was obtained, this person was

deemed eligible and allowed to progress to the next step o f the study.

Eligible individuals were then telephoned within one week and invited to

participate in the study. If they chose to participate, each person was assigned a

research code number to be used on all subsequent forms and randomly assigned into

an immediate treatment or waitlist control condition. Participants in the immediate

condition were scheduled for their first appointment to begin treatment.

Alternatively, those in the waitlist condition were told they would first participate in

an “assessment phase” for which information about their depression would be

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. gathered in advance to starting therapy. These participants then came into the clinic

every other week, for a total of three visits, while on the 6-week waitlist. During this

visit, participants simply filled out the BDI-II and a subsequent appointment was

scheduled. If the participant scored at least a 20 on the BDI-H at the end of six

weeks, they were scheduled for their first appointment to begin treatment.

Participants in both the immediate and delayed treatment conditions

underwent 10 one-hour sessions of BA on a weekly basis. The treatment of BA was

delivered in a standardized manner by a therapist at the Psychology Clinic, whose

role was, as mentioned previously, very similar to that of a “personal trainer.” At the

very beginning of treatment, therapists clarified that their job was to help clients

identify what was wrong in their lives and guide them in finding activities and

behaviors that provide them with the pleasure and interest that was absent from their

lives. This rationale was delivered with optimism, as clients were encouraged to

consider changes in their behavior that would in turn lessen their depression

(Jacobson et al., 1997).

Each BA treatment session involved a distinctive beginning, middle, and end.

The beginning of each session included greeting the client and asking them to

complete the BDI-II. Issues that would be covered throughout the rest of the session

were then placed on an agenda as the therapist and client worked collaboratively to

determine the most important topics for that week. Next, the BDI-II was reviewed,

paying close attention to the specific questions that target suicidal behavior and

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. weekly activity levels. Any homework assignments the client completed between

sessions were also discussed.

About 10 minutes into the session, the client and therapist progressed to the

middle of the session where they worked jointly on the previously set agenda items.

The therapist typically did not stray from the prescribed agenda unless an

extraordinary issue arose (e.g., suicidality). Essentially, the middle part o f the session

was used to work on the issues o f importance.

As the session came to a close, the therapist briefly reviewed the topics that

were covered and assigned a between-session assignment in relation to what was

discussed that day. It was the therapist’s responsibility to make sure the homework

was well understood by the client and that it would be completed. As treatment

progressed, the client began to assume responsibility for reviewing the session and

assigning homework to him or herself. Finally, the client was given the opportunity

to comment on that days’ session and a date was set for the next session.

After 10 weeks o f treatment, each participant returned to the clinic the

following week for a post-test session. Each participant met with a clinical assessor

who administered the BDI-II and the SCID-NP. Finally, the assessor independently

completed the RHRSD.

Next, telephone calls were made to schedule a three-month follow-up

appointment. During this visit, participants completed the BDI-H and were

interviewed with the SCID-NP. Again, the assessor independently completed the

RHRSD. At this time, assessment was complete and participants’ involvement in the

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. study was concluded. Research folders were then closed and transferred to the

Department o f Psychology at Western Michigan University where they will remain in

a locked cabinet for at least three years. They will then be destroyed.

Finally, the research data for each participant was kept in personal folders in a

locked filing system established at the Psychology Clinic. Maintaining these filing

systems and participant folders was the responsibility o f the researcher. A master list

(Appendix G), used to ensure the confidentiality o f the research data, was the only

link between participants and their research code numbers. Additionally, a universal

data collection form (Appendix H) was used to record all assessment information for

each participant. Progress notes and other clinic related treatment documentation for

each participant were kept separate from the research data and was managed by the

Psychology Clinic.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. CHAPTER IV

RESULTS

Analysis Plan

For this investigation, it was hypothesized that depressive symptoms would

decrease for individuals in the immediate and waitlist comparison groups only after

treatment had been administered to each group (see Figure 1). Principal measures

included outcome ratings on the Beck Depression Inventory-II and Revised Hamilton

Rating Scale for Depression.

25 "TX Group M 20 ■WL Group os o 15 O CD 10

0 - I----- Pretest 6 Weeks Posttest Follow-up

Figure 1. Projected Therapeutic Gains on the BDI-H for the Total Sample, by Condition.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. In order to test this hypothesis, this study incorporated a pretest/post-test

waitlist comparison group and included a 2 X 3 repeated-measures design. Two

levels of the between-group factor included the waitlist and immediate treatment

conditions. Three levels of the within-group factor consisted o f assessment time

(pretest, post-test, and follow-up). All participants were randomly assigned into an

immediate treatment or waitlist control condition. A planned comparison between

individuals receiving immediate treatment versus those assigned to a 6-week waitlist

was expected to demonstrate whether the treatment was effective. Likewise, it was

expected that waitlist-assigned individuals would demonstrate symptom reduction

only after they had received the BA intervention. The within-group comparisons

were expected to reveal change for subjects from pretest to post-test for both

conditions, with a stable symptom pattern for the waitlist-assigned individuals during

their pretreatment phase.

Analyses were computed for all participants who fulfilled minimum

requirements of their assigned condition. For both groups, data were included in the

analysis if participants completed a minimum of six sessions of BA. The first

primary analysis of the study consisted o f a repeated-measures analyses of variance

(ANOVA) that examined outcome measures across time for participants in both

groups who completed BA. Given the significant omnibus F-tests, follow-up paired

f-tests were computed separately for each dependent variable and time course. More

specifically, for the immediate treatment condition, differences on each dependent

measure were examined between (a) pretest and post-test, (b) pretest and 3-month

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. follow-up, and (c) post-test and 3-month follow-up. For the waitlist condition,

differences on dependent measures were examined at those same assessment points,

but also between (d) the beginning and end of the waitlist assessment.

In order to detect differences in depression levels between the immediate

treatment and waitlist condition, further comparisons were made at (a) pretest, (b)

post-test, and (c) 3-month follow-up. Independent samples r-tests were performed at

those time periods with BDI-II and RHRSD scores as dependent variables.

So as to maximize the number of total participants entered into the analyses,

and therefore increase the power of the study, the immediate and waitlist group data

were thereupon combined and assessed for change over time. Repeated-measures

ANOVA’S were performed on the collapsed group. Planned within-group

comparisons in mean BDI-II and RHRSD scores for this total sample were then

examined between (a) pretest and post-test, (b) pretest and 3-month follow-up, and (c)

post-test and 3-month follow-up. In a subsequent ‘missing data’ analysis, post-test

scores for each participant were carried forward to substitute for the missing follow-

up data where necessary. These analyses were also conducted using multiple

repeated-measures ANOVAS, along with within-subject contrasts to detect exactly

where the differences between times existed.

Because this computation added only two more participants into the analysis,

a subsequent ANOVA was employed. Instead o f post-test BDI-II scores, week-10

BDI-II scores were carried forward and placed into missing post-test and follow-up

cells respectively. This makes intuitive sense given only one week passed between

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. session 10 and the post-test assessment time. This procedure added five more

participants into the analysis. Because therapists did not assess participants with the

RHRSD at session 10, this analysis was only completed using BDI-II scores.

In a final attempt to include all 17 participants in the collapsed group analysis,

a less conservative ANOVA was subsequently conducted. It was possible to include

all 17 participants by taking the mean BDI-II and RHRSD scores for the whole

distribution at a point in time (pre-, post-, and follow-up) and substituting that number

for the missing data for each variable accordingly. Finally, an intent to treat analysis

was performed on the entire sample to control for attrition.

Preliminary Analyses

Demographic information for the entire sample (i.e., completers and dropouts)

is displayed in Table I. O f the 17 participants who completed the study, 65% were

male (n = 11) and 35% were female (n = 6). The mean age o f participants was 37.8

years old with a range from 20 to 61 years of age. At the time of evaluation, the

racial composition of the group was 94% Caucasian and 6% Alaskan-American.

Nearly one-half of the participants were divorced (47%); the remainder was

single/never married (41%), or married (12%). All participants in the study reported

receiving their high school diploma. A total of 12% of the group completed high

school or received their GED, 47% reported their years of education as more than 12

years, but less than 16, while 18% received at least 16 years o f schooling, and 23%

reported receiving 16-plus years o f education. The household income o f the group

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table I

Demographic Variables for Completers, Dropouts and the Total Sample

Variable Completers Dropouts Total Sample (n = 14) (n = 14) (n = 13)

Gender Male 11 (64.7%) 8 (57.1%) 19 (61.3%) Female 6 (35.3%) 6 (42.9%) 12 (38.7%)

Mean Age 37.8 38 37.9

Ethnic Group African American 0 ( 0.0%) I ( 7.1%) 1 ( 3.2%) Hispanic 0 ( 0.0%) I ( 7.1%) I ( 3.2%) International 0 ( 0.0%) I ( 7.1%) 1 ( 3.2%) Alaskan American I ( 5.9%) 0 ( 0.0%) 1 ( 3.2%) Caucasian 16 (94.1%) 10 (71.4%) 26 (83.9%) Did Not Report 0 ( 0.0%) I ( 7.1%) 1 ( 3.2%)

Relationship Status Single, Never Married 7 (41.2%) 5 (35.7%) 12 (38.7%) Divorced 8 (47.1%) 3 (21.4%) 11 (35.5%) M arried 2 (11.8%) 6 (42.9%) 8 (25.8%)

Years o f Education Less than 12 Years 0 ( 0.0%) 2 (14.3%) 2 ( 6.5%) 12 Years or GED 2 (11.8%) 3 (21.4%) 5 (16.1%) M ore than 12, Less than 16 8 (47.1%) 5 (35.7%) 13 (41.9%) 16 Years 3 (17.6%) 0 (0.00%) 3 ( 9.7%) 16+ Years 4 (23.5%) 4 (28.6%) 8 (25.8%)

Household Income Under $10,000 Per Year 4 (23.5%) 4 (28.6%) 8 (25.8%) $10,000 to $20,000 Per Year 5 (29.4%) 2 (14.3%) 7 (22.6%) $20,000 to $30,000 Per Year 4 (23.5%) 3 (21.4%) 7 (22.6%) Over $30,000 Per Year 4 (23.5%) 3 (21.4%) 7 (22.6%) Did N ot Report 0 (0.00%) 2 (14.3%) 2 ( 6.5%)

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. was 24% earning under $10,000/year, 29% between $10-20,000/year, 24% between

$20-30,000/year, and 23% earned over $30,000/year.

Background data related to mental health history was also collected for each

person who completed and dropped out of the investigation (see Table 2). O f the 17

completers, 13 participants entered the study with an Axis I diagnosis of Major

Depressive Disorder, Recurrent/Moderate, while two participants were diagnosed

with Major Depressive Disorder, Recurrent/Severe without psychotic features. One

participant suffered from Major Depressive Disorder, Recurrent/Mild and one from

Major Depressive Disorder, Single Episode/Mild. It should also be noted that the

SCID-NP also identified three participants with Dysthymia, rendering them a formal

diagnosis of “double depression.” No participants obtained a formal Axis II

diagnosis. On Axisin, one participant reported high blood pressure, one suffered

from high cholesterol, one reported carrying a diagnosis o f multiple sclerosis, and one

reported having diabetes. Twelve participants did not qualify for an Axis III

diagnosis. For Axis IV, one participant reported parent/child relational problems, one

reported economic problems, two participants reported relational problems-NOS, and

six participants reported occupational problems. Furthermore, seven participants

reported a secondary Axis IV diagnosis of problems with primary support group (n =

3), relational problems-NOS (n = 1), parent/child relational problems (n= I),

academic problems (n = I), and economic problems (n = 1). One participant was

given a third Axis IV diagnosis o f occupational problems. Five participants were not

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 2

Clinical Characteristics o f Completers and Dropouts

Variable Completers Dropouts (n = 17) (n = 14)

Medication Status Yes 5 (29.4%) 6 (42.9%) No 12 (70.6%) 8 (57.1%)

Current RX Prozac 2 (11.8%) 2 (14.3%) Celexa 2 (11.8%) 0 (0.00%) Paxil I ( 5.9%) I ( 7.1%) Remeron 0 (0.00%) I ( 7.1%) Did N ot Report 0 (0.00%) 2 (14.3%)

Previous TX for MDD Yes 11 (64.7%) 13 (92.9%) No 6 (35.3%) 0 (0.00%) Did Not Report 0 (0.00%) 1 ( 7.1%)

Number of TX Episodes 0 6 (35.3%) 0 (0.00%) I 2 (11.8%) 3 (21.4%) 2 0 (0.00%) 2 (14.3%) 3 1 ( 5.9%) 0 (0.00%) 4 o r more 2 (11.8%) 4 (28.4%) Did Not Report 0 (0.00%) 5 (35.7%)

Note. RX = Prescription; TX = Treatment; MDD = Major Depressive Disorder.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. given an Axis IV diagnosis. Finally, the Axis V Global Assessment of Functioning

(GAF) scores ranged from 51-68, with a mean GAF of 60.

When asked to describe any existing treatment for depression at the time of

the initial screening, five participants (29.4%) reported taking one psychotropic

medication to treat their depression. Two of those participants reported taking

Prozac, two were being treated with Celexa, and one reported taking Paxil. A

majority of participants (70.6%; n = 12) reportedly were not using medication for

their depression. All 17 participants reported they were not concurrently receiving

another type of psychotherapy. In regards to previous episodes of treatment for

depression, two participants reported they had received one previous episode of

treatment, one had received three previous episodes of treatment, and two participants

reported receiving four or more episodes of treatment for their depression in the past.

Twelve participants reported this episode of treatment as their first.

Demographic information for dropouts (i.e., those who terminated treatment

before completing at least six sessions) is also displayed in Table I. Of the 14

dropouts, 8 (57.1%) were male and 6 (42.9%) were female. The mean age for this

sample was 38 years old, with a range from 19 to 66 years of age. The racial

composition o f this group was 71.4% Caucasian, while African-American, Hispanic,

and intemational/non-US citizen each made up 7.1%. One person did not report their

ethnicity. Forty-three percent o f dropouts were married; the remainder was

single/never married (35.7%) or divorced (21.5%). Two individuals (143%) who

dropped out o f the study reported not completing high school, 21.4% reported

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. completing high school or GED, while the remaining 64.3% reported their years of

education as more than 12 years of education. The household income o f this group

was 28.6% earning under $ 10,000/year, 14.3% between $10-20,000/year, 21.4%

between $20—30,000/year, and 21.4% over $30,000/year.

The clinical characteristics o f those who dropped out are also shown in Table

2. All 14 dropouts entered the study with an Axis I diagnosis of Major Depressive

Disorder. Over half (57.1%) o f the dropouts reported their depression as

recurrent/moderate. Moreover, single and recurrent episode/moderate and recurrent

episode/severe each made up 14.3%. On the remaining axes, those who terminated

treatment prematurely did not report clinical information that made them significantly

different from those who completed treatment.

When asked to describe any existing treatment for depression at the time of

the initial screening, slightly one-half of dropouts (42.9%; n = 6) reported taking one

psychotropic medication. The remaining 57.1 % (n = 8) reportedly were not taking

medication for their depression. All 14 dropouts reported they were not concurrently

receiving another type o f psychotherapy, hi regards to previous episodes o f treatment

for depression, three participants reported they had received one previous episode of

treatment, two had received two episodes o f treatment, and three reported receiving

four or more episodes o f treatment for their depression in the past. Five dropouts

reported this episode of treatment as their first.

In regards to the point at which these individuals dropped out o f the

investigation, over one-half (64.3%; n = 9) o f the 14 dropouts terminated participation

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. after intake but before they were randomized into the immediate treatment or waitlist

condition. O f the five people who actually began treatment, three were randomized

into the immediate treatment group and two into the waitlist group. Moreover, a

single person dropped out after session one, after session three and after session four,

while two people terminated after session two. Finally, it may be important to note

that those who dropped out were not significantly more or less depressed at the initial

screening than those who completed the study, according to the BDI-II,t(29) = 0.74,

p — ns, and the RHRSD, f(29) = 0.61,/? = ns.

Primary Analyses

The means, standard deviations, and results of the between group analyses are

presented in Table 3 and Figure 2. The first point of analysis consisted o f an

Table 3

Mean Pre-waitlist and Post-waitlist BDI-II Scores for Waitlist Participants and Mean BDI-II Pretreatment, Post-treatment, and 3-Month Follow-up BDI-H Scores for Treatment Participants

TX Group WL Group n M SD n M SD r(dfs) andp

Pre- 9 32.78 (6.3) 8 29.75 ( 5.58) r(15)=1.04,/? = ns

Post- 6 3.83 (3.3) 8 28.30 (16.32) r(12)=3.58, pZ 0.004 Follow-up 6 7.17 (8-2) 8 28.30 (1632) t(12)=2.88,/?Z0.02 Note. BDI-II = Beck Depression Inventory-Second Edition; TX= Treatment; WL = W aitlist.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 35

BPre IS Post S Follow-up

TX Group WL Group

Figure 2. Mean Pre-Waitlist and Post-Waitlist BDI-II Scores for Waitlist Participants and Mean PreTreatment, Post-Treatment, and 3-Month Follow-up BDI-II Scores for Treatment Participants.

independent-samples r-test to assess group differences at intake. There were no

significant differences at time o f initial intake on both the BDI-H, r(l 5) = 1.04,p = ns,

or the RHRSD, r(15) = 0.94, p = ns. This suggests that both immediate treatment and

waitlist conditions started treatment at comparable levels of symptom severity (see

Table 4 and Figure 3).

The next point o f analysis examined group BDI-H means immediately

following treatment for those in the immediate treatment group and immediately

following the waiting period for those in the waitlist group. The results of this

independent samples f-test was significant, r(12) = 3.58,p < 0.004, r =0.72. In a

similar analysis, an independent samples r-test compared group means at the same

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 4

BDI-II and RHRSD Scores at Pretreatment

TX Group fn = 91 WL Group (n — 22) Variable M SDM SD *df) andp

BDI-H 32.8 (63) 29.8 (5.6) r(15) = 1.04, p = 0.32 RHRSD 18.1 (4.0) 20.0 (4.2) *15) = 0.94,p = 0.36

Note. TX = Treatment; WL = Waitlist; BDI-II = Beck Depression Inventory- Second Edition; RHRSD = Revised Hamilton Rating Scale for Depression.

15 STX Group 10 EH WL Group 5

0 BDI-II RHRSD

Figure 3. Mean BDI-II and RHRSD Scores at Pretreatment.

point for the waitlist condition but at 3-month follow-up for the immediate treatment

condition. This analysis revealed statistically significant differences in mean BDI-II

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. scores with /(12) = 2.88, p < 0.02, r = 0.64. These results suggest that treatment with

BA was superior to remaining on a waitlist and that it was simply not the passage of

time that caused reductions in depression.

The next independent sample r-tests compared means at post-test on each

dependent variable and significant differences were found between the groups, with

f(6) = 2.63, p < 0.04, r = 0.73 on the BDI-II andt(5) = 5.04, p < 0.004, r = 0.92 on the

RHRSD. This result suggests that on both dependent measures, those in the

immediate treatment condition were significantly less depressed than those in the

waitlist condition after receiving BA treatment, but at the 3-month follow up,

significant differences were not found on the BDI-II [f(7) = 0.21,/? = ns], but

apparent on RHRSD scores,t(7) = 2.55, p < 0.04, r = 0.69. With respect to the

RHRSD, the significant difference suggested that the immediate treatment group

showed the greatest reduction in symptoms.

Although both immediate and waitlist groups started out with comparatively

similar depression levels, after receiving treatment, one group appeared more

depressed than the other. This result should be interpreted cautiously as only two

waitlist condition participants entered into the analysis at post-test for each outcome

measure, and three waitlist condition participants at follow-up on each outcome

measure. Despite low participant numbers, effect sizes for each independent r-test

appear large enough to conclude that BA treatment is more effective in decreasing

depression when compared to a 6-week wait period and that participant’s depression

levels did not decrease simply due to passage o f time.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. The next set of analyses was computed within-groups for the immediate and

waitlist conditions separately over three assessment times (i.e., pretest, post-test, and

follow-up) on both dependent measures (see Figures 4 and 5). For the immediate

treatment group, there was a significant reduction in BDI-II scores from pretest

through to follow-up, w ithF(2, 8) = 82.15, p <0.001, eta = 0.97. Results were

similar for RHRSD scores, with F (2, 8) = 140.77, p < 0.001. eta = 0.99. Given the

significant omnibus F-tests, within-subjects contrasts were computed on both

dependent measures. Significant reductions in scores were found between pretest and

post-test on the BDI-H, F (1,4) = 93.52,p < 0.001, eta = 0.98, and the RHRSD, F (l,

4) = 196.00, p < 0.001, eta = 0.99. Likewise, significant reductions in depression

scores between pretest and follow-up were found on the BDI-II, F (l, 4) = 90.99,/? <

0.001, eta = 0.98, and the RHRSD, F (l, 4) = 130.0,/? < 0.001, eta = 0.98. A final

within-subjects contrast examined means at post-test versus 3-month follow-up.

There was no significant differences found at these points on both the BDI-II, F (l, 4)

= 0.022,/? = ns, and the RHRSD, F (l, 4) = 3.33,/? = ns. These results suggest that

for those in the immediate treatment group, depression levels decreased significantly

overtime. Furthermore, these individuals maintained treatment gains for at least

three months after finishing BA treatment.

Because only three participants finished treatment through to the 3-month

follow-up in the waitlist condition, it was not possible to conduct a repeated-measures

ANOVA on this group separately. Alternatively, paired samples f-tests were

performed on both dependent measures. The results o f the pretest to post-test

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 35

25 (0 £ 8 20 ■TX Group co ' WL Group l 15 5 m

Pretreatment Posttreatment Follow-up Figure 4. Pretreatment, Post-treatment, and 3-Month Follow-up Means for BDI-H Scores, by Condition.

20 ■TX 15 Group — •WL

0 -I------1------.------Pretreatment Posttreatment Follow-up

Figure 5. Pretreatment, Post-treatment, and 3-Month Follow-up Means for RHRSD Scores, by Condition.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. comparison showed a significant reduction in BDI-H scores, with f(l) = 31.0,p =

0.02, but not RHRSD scores, with f(l) = 3.33, p = ns. The second comparison of

means, between pretest and follow-up, showed no significant change in BDI-II

scores, with t{2) = 2.65, p = ns. On the contrary, a significant difference was found at

this same point in RHRSD scores, witht(2) = 4.5, p < 0.05. The comparison between

post-test and follow-up means could not be calculated, as there were not enough

participants to enter into the analysis.

In order to control for the relatively small sample size, the immediate and

waitlist groups were then combined, allowing for a within-subjects comparison from

intake to post-test to the 3-month follow-up. Prior to collapsing the two groups, it

was necessary to show that participants in the waitlist condition did not change (i.e.,

become significantly more or less depressed) from the initial screening to the end of

the 6-week wait period. A repeated-measures ANOVA, examining the means at

pretest through to the end o f the 6-week waitlist period showed that participants’

depression levels remained uniformly the same,F (3,21) = 0.101, p = ns.

Given this non-significant finding, the immediate and waitlist conditions were

then collapsed and assessed for change over time. This analysis was performed for

all participants who completed at least six sessions o f treatment, regardless o f their

treatment condition. Although only 6 of 17 participants completed all outcome

measures at pretest, post-test and follow-up, results revealed a significant reduction in

both BDI-II scores, F (2 ,10) = 47.34,/? <0.001, eta = 0.95, and RHRSD scores,F (2,

10) = 83.68, p <0.001, eta = 0.97. Furthermore, within-subject contrasts revealed a

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. significant reduction in BDI-H scores from pretest to post-test, F (1,5) = 70.68,p <

0.001, eta = 0.97, and in RHRSD scores at that same assessment point,F (1, 5) =

81.22,/? < 0.001, eta = 0.97. Similarly, within-subjects contrasts revealed a

statistically significant reduction in BDI-II scores from pretest to follow-up, F (l, 5) =

40.86, p = 0.001, eta = 0.99, and in RHRSD scores at that same assessment point,F

(1, 5) = 116.02, p < 0.001, eta = 0.98. Depression levels remained at a relative

constant from post-test to follow-up as significant differences were not found on both

the BDI-II, F (l, 5) = 0.30, p = ns, or the RHRSD, F (1, 5) = 0.56, p = ns.

In the next analysis, post-test scores for each participant were carried forward

to complete the missing follow-up data where necessary. A repeated-measures

ANOVA on the total sample revealed a significant reduction from pretest through to

the 3-month follow-up on both the BDI-H, F (2, 14) = 66.69, p < 0.001, eta = 0.95,

and the RHRSD,F (2,12) = 117.59, p < 0.001, eta = 0.98. Further within-subject

contrasts unveiled a significant reduction in BDI-II scores from pretest to post-test,F

(1, 7) = 89.33,/? < 0.001, eta = 0.96, and in RHRSD scores from pretest to post-test,F

(1,6) = 114.09, p < 0.001, eta = 0.97. Similarly, within-subjects contrasts revealed a

statistically significant reduction in BDI-II scores from pretest to follow-up, F (l, 7) =

59.7, p < 0.001, eta = 0.95, and in RHRSD scores at the same assessment point, F (1,

6) = 163.36, p < 0.001, eta = 0.98. Depression levels remained at a relative constant

from post-test to follow-up as significant differences were not found on both the BDI-

II, F ( l , 7) = 0.31, p = ns, or the RHRSD, F (l, 6) = 0.56, p = ns.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Unfortunately this computation added only two more participants (n = 8) into

the analysis, so a similar ANOVA was employed increasing the sample size to 13.

For those who finished ten weeks of BA, their 10-week BDI-H score was carried

forward and placed into missing post-test and follow-up cells respectively. The

results yielded a statistically significant difference over time from pretest through to

follow-up, F(2, 24) = 73.00 , p < 0.001, eta = 0.93. Further within-subjects contrasts

revealed exactly where those differences existed. As would be expected, there was

significant differences between pretest and post-test, F (l, 12) = 87.81, p < 0.001, eta

= 0.94, and between pretest and follow up,F (1, 12) = 83.64, p < 0.001, eta = 0.94.

Participants BDl-H scores stayed relatively constant from post-test to follow-up, F (l,

12) = 0.96, p = ns.

So as to include all 17 participants and increase the power in the collapsed

group analysis, a less conservative ANOVA was subsequently conducted (see Table S

for means and standard deviations and Figure 6). It was possible to include all 17

participants by taking the mean BDI-II and RHRSD scores for the whole sample at a

given point in time, and placing that mean into the missing data for each variable

accordingly. Statistically significant differences were found from pretest through to

follow-up on the BDI-H, F (2,32) = 180.69, p < 0.001, eta = 0.96, and on the

RHRSD, F (2 ,32) = 223.19, p < 0.001, eta = 0.97. Given the significant results,

further within-subject contrasts were computed. Significant differences were found

between pretest and post-test on the BDI-II, F (1,16) = 266.89,p < 0.001, eta = 0.97,

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 5

Pretreatment, Post-treatment, and 3-Month Follow-up Means for BDI-n and RHRSD Scores for the Total Sample

Depression Measure n M (SD) F(dfs) andp BDI-H Across time 17 F ( 2, 32) = 180.69, p < 0.00l a Pre- 17 3135 (6.0) F (l, 16) = 266.89, /?<0.001b Post- 17 5.94 (3.4) F (l, 16) = 1.92,/?

RHRSD Across time 17 F (2,32) = 223.19, p < 0.001“ Pre- 17 19.0 (4.1) F ( l , 16) = 228.25,/? < 0.001b Post- 17 3.82 (1-8) F (l, 16) = 0.21,/? <0.00 lc Follow-up 17 4.0 (1.3) F (l, 16) = 255.00,/? < 0.001d

Note. BDI-H = Beck Depression Inventory-Second Edition; RHRSD = Revised Hamilton Rating Scale for Depression; TX = Treatment; WL = Waitlist, “pretreatment to post-treatment to follow-up; b pretreatment to post-treatment; c post-treatment to follow-up; d pretreatment to follow-up.

and on the RHRSD, F (l, 16) = 228.25,p < 0.001, eta = 0.97. Similar differences

were found between pretest and 3-month follow-up on both outcome measures, F ( 1,

16) = 220.58, p < 0.001, eta = 0.97, on the BDI-H, an d F (l, 16) = 255.0,/? < 0.001,

eta = 0.97, on the RHRSD. Statistically significant differences were not found

between post-test and 3-month follow-up on BDI-H scores,F (1,16) = 0.96, p = ns,

and RHRSD scores, F (l, 16) = 0.21,/? = ns.

Although calculated in different manners, these various analyses for the total

sample suggest that a significant reduction in depression scores existed from

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 35

20 Mean BDMI Scores

15 Mean RHRSD

0 - I------Pretreatment Posttest Follow-up

Figure 6. Pretreatment, Post-treatment, and 3-Month Follow-up Means for BDI-H and RHRSD Scores for the Total Sample.

pretreatment to post-treatment, while those gains were maintained respectively at the

3-month follow-up point. Overall, it implies that depression levels decreased

significantly for those participants who received six or more sessions of BA.

Intent-to-Treat Analyses

In order to control for participants who dropped out of the study, an intent-to-

treat analysis was performed by utilizing the dropouts’ pretest scores on both

dependent measures as their post-treatment scores. The following analysis is

particularly meaningful for this study due to the high attrition rate, established at

approximately 45% (14 o f 31 participants dropped out).

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Because this analysis assumes that those who prematurely dropped out o f the

study achieved no gains from BA treatment, this is considered a conservative

analysis. This analysis guides our understanding regarding whether BA was effective

for the entire sample, as opposed to just those who completed the study. For the

intent-to-treat analyses, changes in BDI-H scores, RHRSD scores, and changes in

diagnosis from pretest to post-test were examined. Paired samples r-tests showed a

significant reduction in depression symptomatoloy in both BDI-II scores, r(31) =

6.24, p < 0.001, r = 0.75, and RHRSD scores, r(31) = 2.86, p < 0.01, r= 0.46. These

analyses suggest that even when controlling for dropouts, BA was associated with a

significant reduction in depression levels. Furthermore, BA was associated with a

significant reduction in the number of Major Depression diagnoses from pretest to

post-test, even when dropouts were factored into the analysis, f(30) = 3.23,p < 0.01, r

= 0.51.

Post-hoc Analyses

In order to clarify the role of behavioral activation in the treatment of more

“real world” people who suffer from Major Depressive Disorder, comparisons were

made between persons who were and were not being treated with psychotropic drugs.

These are the people who realistically present themselves in practice settings for

treatment. Therefore, a set o f post-hoc analyses were conducted by separating those

participants who were receiving independently prescribed pharmacological treatment

for depression while receiving BA from those who were receiving only BA (i.e.,

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. medication participants versus no medication participants). Each sample was

examined at three assessment points (i.e., pretest, post-test, and follow-up) and mean

BDI-II and RHRSD scores served as dependent variables. For this sample of

participants who completed the treatment, approximately one-third (29.4%) were

taking medications for their depression (n = 5).

Due to similar attrition problems as seen in previous analyses, a more liberal

analysis was computed to increase the number of participants entered into the

analysis. For all between-group and within-group computations, the mean post-test

and follow-up score for that sample was substituted for missing data at each

respective assessment point. Independent samples r-tests with medication status as

the independent variable and BDI-II and RHRSD scores as dependent variables

revealed non-significant findings at each assessment point (see Table 6 and Figures 7

and 8 for details). More specifically, statistically significant differences were not

found at pretest on both the BDI-H, /(15) = 1.09,p = ns, and RHRSD, r(l5) = 1.33,/)

= ns. Also at post-test, results revealed no significant difference between the two

groups on the BDI-H, r(I5) = 1.58,p = ns, and RHRSD, f(15) = 0.91,p = ns. The

same followed at the 3-month follow up, with no significant differences found in

BDI-H scores, r(l5) = 0.62,p = ns, and RHRSD scores, f(15) = 1.28,p = ns. This

analysis suggests that those taking medication did not have higher or lower BDI-H or

RHRSD scores (M =33.8) prior to starting treatment than those who were not taking

medication(M = 30.3). Furthermore, after receiving BA treatment, those that were

taking medication did not achieve significantly lower or higher BDI-H or RHRSD

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 6

Pretreatment, Post-treatment, and 3-Month Follow-up Means for BDI-H and RHRSD Scores as a Function of Medication Status

No Medication Medication n M SD n M SD f(dfs)andp

BDI-H Pre- 12 30.33 (5-2) 5 33.8 (8.7) r(l5) = 1.09, p=ns Post- 12 6.75 (3.5) 5 4.0 (2.3) f(6) = 1.45, p=ns Follow-up 12 7.25 (3.5) 5 9.0 (8.5) r(7) = 0.59,/?=ns

RHRSD Pre- 12 19.83 (4.0) 5 17.0 (4.1) r(15) = 1.33, p=ns Post- 12 4.08 (2.0) 5 3.2 (1.3) t(5) = 0.88, p=ns Foilow-up 12 4.25 (1.4) 5 3.4 (0.9) t{ 7) = 1.21, p=ns

Note. BDI-H = Beck Depression Inventory-Second Edition; RHRSD = Revised Hamilton Rating Scale for Depression.

scores than those who received BA singly. Thus, this analysis does not argue for an

additive effect of medication in this investigation.

A more conservative between-group comparison in which exact pretest, post

test and follow-up data were examined between the medication versus no

medication participants showed very similar results as above, with no significant

differences found at any assessment point on both outcome measures. Again at

pretest, participants did not differ significantly on their BDI-H or RHRSD scores,

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 35

m S o No Meds o CO Meds

Q 15 m

Pretreatment Posttreatment Follow-up

Figure 7. Mean BDI-II Scores as a Function of Medication Status.

20 cn os o CO Q ' No Meds CO X "Meds tcX

Pretreatment Posttreatment Follow-up

Figure 8. Mean RHRSD Scores as a Function of Medication Status.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. r(l 5) = 1.09, p = ns, and /(15) = 1.33,/? = ns. Similar results followed at post-test on

BDI-H and RHRSD scores, f(6) = 1.47, p = ns; /(5) = 0.88,p = ns, and at the 3-month

follow-up on BDI-H and RHRSD scores, f(7) = 0.59,/? = ns;t(7) = 1.21,/? = ns.

In order to describe how each group o f participants respondedBA to

separately, within-group computations were executed. For those being treated with

both medication and BA, a repeated-measures ANOVA was executed, again

implementing the more liberal procedure in which whole sample post-test and follow-

up means are substituted for missing post-test and follow-up data respectively. This

analysis was chosen over the more conservative procedure o f using exact pre-, po st

and follow-up means as only two participants entered into that particular analysis.

Results displayed a significant decrease over time from pretest to post-test through to

follow-up on both BDI-n scores, F (2, 8) = 54.03, p < 0.001, eta = 0.96, and RHRSD

scores, F ( 2, 8) = 59.22, p < 0.001, eta=0.97. Further within-subjects comparisons

were made to detect where exact reductions in depression scores appeared.

Statistically significant differences were found from pretest to post-test on BDI-Hthe

and RHRSD, F ( l , 4) = 102.78,/? = 0.001, eta = 0.9 8 ;F (1 ,4) =67.06, p = 0.001, eta

= 0.97, and from pretest to the 3-month foUow-up on theBDI-H and RHRSD, F ( l, 4)

= 65.85, p = 0.001, eta = 0.97; F ( l, 4) = 56.74, p = 0.002, eta = 0.97. Depression

levels remained relatively constant for this group from post-test to follow-up as no

significant differences were revealed between these assessment points on either the

BDI-H, F (l, 4) =2.43,/? =ns, or the RHRSD, F (l, 4) =0.17,/? = ns.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Similar reductions inBDI-H and RHRSD scores overtime were found for

those participants receiving BA singly. As in the previous analysis, the more liberal

ANOVA procedure was instituted, as opposed to comparing exact means due to low

sample sizes included in this analysis. Results displayed a significant decrease over

time from pretest to post-test through to follow-up on both BDI-II scores, F ( 2 ,22) =

139.48,/? <0.001, eta = 0.96, and RHRSD scores, F ( 2 ,22) = 161.67, p <0.001, eta =

0.97. Given this finding, within-subjects comparisons were made. Statistically

significant differences were found from pretest to post-test on BDI-IIthe and

RH RSD ,F(l, 11) = 210.41,/? <0.001, eta = 0.98; F ( l, 11) = 160.32,/? <0.001, eta

= 0.97, and from pretest to follow-up on theBDI-II and RHRSD, F ( l, 11) = 143.86,

p <0.001, eta = 0 .96;F (l, 11) = 199.20,/? <0.001, eta = 0.97. Depression levels

remained relatively constant for this group from post-test to the 3-month follow-up as

no significant differences were found between these assessment points on either the

BDI-n,F(l, 11) =0.17,/? = ns, or RHRSD, F (l, 11) = 0.10,/? = ns. Overall, the

post-hoc analyses suggest that in this investigation the addition o f medication to BA

treatment does not significantly reduce depression levels any more than treatment

with BA alone.

Diagnostic Outcome and Recovery

In order to assess for clinically significant decreases in depressive

symptomotology, this investigation also compared the number of participants who

met D SM -rV criteria at initial screening to those who met criteria after receiving

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. treatment with BA. The Structured Clinical Interview for DSM-IV determined

diagnostic outcome.

At the initial screening, all 17 completers (100%) met DSM-IV criteria for

Major Depressive Disorder. At the end of treatment, of the three that returned for

assessment at post-test, no participants metDSM-IV criteria for Major Depressive

Disorder. Similarly, at the 3-month follow-up point, no participants out o f the four

that returned for assessment metDSM-IV criteria for Major Depressive Disorder.

This information obtained from the SCID suggests that all participants who returned

for post-test and/or follow-up assessments showed reductions in depressive symptoms

o f a large enough magnitude such that they no longer rendered a formalDSM-IV

diagnosis of Major Depressive Disorder.

In an attempt to further assess clinical significance, recovery rates for Major

Depression were also investigated. Similar to cutoffs used in the Jacobson et al.

(1996) study, those participants who can be considered “recovered” have scores of

less than eight on the BDI-H at post-treatment. Because of the low sample size at

post-test for this study, the last data point for each participant was investigated. For

this sample, approximately one-third (35%) of completers can be classified by the

BDI-H as “recovered” from Major Depressive Disorder attributable to BA, as

compared to the 50-60% of participants considered “recovered” in the Jacobson et al.

(1996) study. It may be important to note that only three of 17 participants (18%)

could still be considered clinically depressed at post-treatment, according to a score

o f 20 or higher on the BDI-H.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Treatment Adherence

In order to be certain that the treatment delivered from the prescribed manual

was in fact BA, treatment integrity data were collected on each participant who

completed the study. Trained observers were provided with a modified version of the

National Institute of Mental Health Collaborative Study Psychotherapy Rating Scale

(CSPRS; Hollon et al., 1984) that included the steps in BA, along with a checklist o f

prescribed BA techniques and proscribed cognitive therapy techniques.

A random sample of the video taped treatment sessions (11%) was reviewed

separately by two different observers (representing 53% o f participants on whom

treatment integrity was completed). Both observers checked off the presence of each

step in the outline, along with the specific treatment interventions used that session.

All therapists were included in the reviewed sample.

In order to determine where rater discrepancies appeared, checklist

compliance percentages for the most relevant items was first computed. On 100% of

the observed occasions, raters responded “yes” to the checklist item, “therapist

implemented behavioral activation interventions.” Furthermore, on 100% of the

observed occasions, raters responded “no” to the item, “therapist did use cognitive

interventions,” indicating cognitive therapy was not implemented at any point

throughout treatment in the observed sessions. This is key to treatment integrity as it

strongly suggests that therapists in fact administered BA, and not cognitive therapy,

to the participants.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Also important in the delivery of BA was the adherence to the prescribed

treatment protocol in terms of completing all procedural components. On 94% of

observed occasions, therapists asked participants to complete the BDI-II at the

beginning of the session and then reviewed the questionnaire, examining overall

scores and key items as that which endorsed suicidal ideation and participation in

activity. Furthermore, therapists and participants reviewed the previous weeks’

homework on approximately 94% o f the observed sessions and then presented

homework to be completed over the upcoming week.

Finally, inter-rater reliability was performed on the final judgment, which

examined the number of agreements divided by the number of agreements plus

disagreements. The inter-rater reliability correlation was .88, showing that the raters

agreed 88% of the time that therapists were delivering BA according to the protocol

described in the treatment manual.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. CHAPTER V

DISCUSSION

The purpose o f the present study was to test the effectiveness of behavioral

activation with medicated and unmedicated clients who realistically presented for

treatment in a more “real-world” setting. The aim of this study was to conduct a

quasi-replication of the basic findings noted in the Jacobson et al. (1996) study, which

concluded that the BA component of CBT was as successful as the full treatment

package in reducing depression and altering negative thinking and attributional styles.

It was hypothesized that at the completion of therapy, participants in both the

treatment and waitlist conditions would be significantly less depressed on both a self-

report measure and a clinician rating o f symptom severity.

Main Outcomes

The results of this study support BA as an efficacious therapeutic tool to treat

major depression and suggest that activation strategies alone may be sufficient to

produce behavioral and cognitive changes that significantly reduce depressive

symptoms. Conclusions are based on between-group differences, which showed that

though both treatment and waitlist conditions started out at comparable levels of

symptom severity, the treatment group had a better response to BA than those in the

waitlist group at post-treatment. These differences were maintained at the 3-month

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. follow-up according to the RHRSD. Essentially, both treatment and waitlist

condition participants experienced a significant decrease in depressive symptoms, but

with respect to a clinician-rated assessment, the treatment group showed a greater

reduction in symptoms. These results should be interpreted with caution due to the

low sample size in the waitlist group.

Further statistical comparisons between groups support the efficacy of BA.

For instance, the comparison made between the end of the wait period for the waitlist

group and post-treatment for the treatment group showed that end of treatment means

were significantly lower than end of the wait period means. These results are

especially meaningful in that they suggest that treatment with BA is superior to

remaining on a waitlist and that it was not simply the passage of time or spontaneous

remission that accounted for apparent decreased symptomatology in this sample.

The inclusion of the waitlist control group and their absence of change over a

6-week wait period in depression symptoms bolster this conclusion. Essentially,

participants in the waitlist group showed no significant reduction in BDI-II scores

over the course of the wait period, again suggesting that the passage of time was not

sufficient to decrease depressive symptomatology. Moreover, as waitlist participants

began treatment with BA, they subsequently experienced a reduction in

symptomatology.

In sum, those in the treatment group showed a significant decrease in

depression, as they experienced a shift; from moderate/severe to mild depression (as

measured by the BDI-II). Those who were in the waitlist control group, waiting for

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. treatment to begin, did not show improvement over the 6-week wait period. Put

simply, for this sample, when treated with BA, people experienced a decline in

depression symptoms. Without treatment, depression levels falling in the

moderate/severe range remained relatively the same.

Given that the treatment and waitlist conditions experienced a significant

reduction in depression when assessed separately, it makes intuitive sense that after

combining the groups, BA still fared well. Overall, depression levels significantly

decreased for those who received six or more sessions of BA. Furthermore, there

were no significant differences between the end of treatment and 3-month follow-up

scores on both outcome measures. More specifically, for this sample, even three

months after treatment ended, significant reductions in depression were still evident.

As noted by Gortner et al. (1998), this comparison is important as it allows for the

determination of the “ultimate impact of therapy,” showing both acute and longer-

term responses to treatment (p. 379). This is an important point to highlight given the

greatest risk for relapse is during the immediate post-recovery period, typically

around the first few months after symptoms remit (Keller, Lavori, Lewis, & Klerman,

1983; Maj, Veltro, Pirozzi, Lobrace, & Magliano, 1992).

Moreover, this sample as a whole scored in the moderate/severe range of

depression(M = 30.6) at the initial screening, according to the BDI-II. After

receiving at least six weeks of treatment, the post-treatment mean (Af = 8) placed this

group in the minimal clinical depression category. This finding is similar to the BA

group in the Jacobson et al. (1996) study in which participants also moved from a

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. moderate/severe level o f depression to mild clinical depression, as measured by the

BDI-H. Furthermore, 15 out o f 17 participants (88.3%) who entered this study

initially described themselves as suffering from chronic, recurrent depression. This is

not surprising given the risk for repeated episodes o f depression is approximately

80% and isolated depressive episodes are rare (14%; Judd, 1997). This closer

examination of symptom severity and chronicity is meaningful in showing that BA

was not simply sustaining a group of people suffering from a mild or subclinical level

depression, or primarily those experiencing their first single episode of depression. It

had a considerable effect on a difficult to treat population, those primarily suffering

from moderate to severe cyclical depression, quite possibly for a number of years.

Given these findings, one cannot dispute the clinical effectiveness of BA for

the treatment of major depression. Questions as to its theory of change and the

decision to use BA singly or in combination with CT, therefore need to be addressed.

Dating back to 1984, treatment outcome researchers began to question the cognitive

component of CBT for depression, pondering whether “changing beliefs necessarily

solves the clinical problem” (Latimer and Sweet, 1984, p. 21). As Latimer and Sweet

(1984) critically reviewed the evidence for the efficacy of procedures specific to

behavioral and cognitive therapy, they inquired whether the cognitive piece of CBT

was a direct mechanism of change, or if the clinical shift was due to the use of

behavioral procedures of established efficacy. Based on their review o f 11 studies, it

was concluded that because CT usually involves a variety of methods including

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. behavioral procedures, it’s questionable whether the cognitive piece alone makes a

significant contribution to therapeutic outcomes.

Over the next decade, this line o f inquisition spawned much theoretical

debate, along with a line of solid clinical research comparing combined cognitive-

behavioral treatment packages. A further review of treatment outcome research,

published from 1982 through to 1989 (Sweet & Loizeaux, 1991), examined 70

articles that addressed the essential question: “Does the specific addition of a purely

cognitive therapeutic procedure enhance the outcome of behavioral treatment

methods for actual patient populations?” In this comparative review, most studies

reflected an equivalence in outcome between CBT procedures and behavioral

procedures alone, therefore allowing the authors to conclude that the behavioral

aspect o f CBT was central to its effectiveness, while the same could not be said for

the cognitive component. Given this conclusion, the authors ingeniously proposed

the need for clinical researchers to dismantle CBT.

As noted by Beidel and Turner (1986), the relationship between behavior and

cognitive change is “complex and interactive, with change in one domain promoting

change in the other” (p. 188). These authors have suggested that we can get positive

outcome from behavior therapy alone, without the cognitive component, because

behavioral activities provide a mechanism through which distorted cognitions can be

evaluated, thus rendering a subsequent cognitive shift Furthermore, as patients are

encouraged in CBT to evaluate their thoughts in a more critical light, it has been

argued that what they are actually attending to is a more careful self-monitoring of

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. environmental contingencies, which fits nicely into a stimulus discrimination

paradigm. As patients are encouraged to try new behaviors and monitor the

consequences, cognitive change occurs as a result. This then describes CBT as not

very different from the more traditionally oriented behavior therapy, as both look to

change overt and covert maladaptive depressive behaviors (Biedel & Turner, 1986).

This investigations’ ability to show that in and of itself, BA is an effective

treatment for depression, supports these theoretical underpinnings and refutes what

cognitive therapists have long said about the mechanisms o f action in CBT for

depression. First described in the Jacobson et al. (1996) study, it was suggested that

BA can be just as effective as the full CBT treatment package because as reinforcers

are returned to depressives’ lives, BA functions to change the way people think more

effectively than explicit cognitive interventions. This line of reasoning supports

traditional behavioral theory, which stresses the importance of learning histories for

subsequent variation in cognitive content, and helps explain why BA may stand alone

as an efficacious treatment intervention for major depression.

Secondary Outcomes

In this investigation, comparisons were made post-hoc between persons who

were and were not being treated with psychotropic drugs. This was done so as to

clarify the role of BA in the treatment of more “real world” people who suffer from

major depression. As noted by Burrows (1992), when patients present for therapeutic

treatment for depression in a clinic setting, many are already taking psychotropic

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. medication, leaving psychotherapists to contend with existing medication regimes.

Therefore, this study set out to simulate a typical clinical setting as much as possible,

thus making this important post-hoc comparison.

The medication and no medication groups were statistically compared at

pretreatment, post-treament, and the 3-month follow-up. While within-group

comparisons revealed both groups experienced significant reductions in depressive

symptoms, neither group proved superior to the other with regard to both outcome

measures. Essentially, the combination of preexisting medication and BA did not

provide a clinically meaningful advantage over BA alone.

While preexisting medication did not seem to hinder the recovery o f those in

the medication and BA treatment group, it appears that medication also did not

enhance positive treatment outcome. One might argue that because combining the

two interventions did not exceed that of BA alone, it would be more cost-effective to

use BA singly. As suggested by Antonuccio, Thomas, and Danton (1997), in an era

of managed care, treatment must not only be effective, but also cost-effective. In a

study conducted by these same authors in which acute and long-term outcomes and

dropout/relapse rates were considered over a 2-year period, medication alone resulted

in 33% higher expected costs than individual CBT treatment, while the combination

of treatments resulted in 23% higher costs than CBT alone. Although only one study,

it makes a strong argument that getting treated with therapy alone can be greatly cost-

effective in comparison to treatment with medication alone or some combination of

therapies. This cost-effective model bodes well for BA as a single therapeutic tool,

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. which proved for this sample to be efficacious for treating depression whether

patients were taking antidepressant medication or not.

One might ask why two therapeutic interventions were not more effective in

this investigation for reducing depression symptoms than a single approach. Not only

has some preliminary evidence supported the fact that patients who improve with

cognitive-behavioral therapy show similar biological changes than those who

improve with psychotropic medication (Antonuccio, Danton, DeNelsky, Greenberg,

& Gordon, 1999), but it is also possible that those who were prescribed a medication

regime were not completely compliant. Non-adherence to antidepressant medication

regimes is not uncommon, as the research suggests that 40—50% o f patients

prescribed an antidepressant will not take it for the maximum period needed to

achieve therapeutic gains. Discontinuing the medication because of undesirable side

effects is also common (Schulberg, Katon, Simon, & Rush, 1999). With this sample,

it is possible that the medication participants who were reportedly taking their

medication as prescribed had in fact discontinued it over the 10-week treatment

period or were not taking it consistently. Similarly, it is possible that participants

were not taking the therapeutic dosage (i.e., dosages were suboptimal) necessary to

clinically reduce depression. Because participants’ medication compliance and

dosage levels were not monitored by present investigators at any point during their

involvement in the study, it is impossible to know exactly how compliant they were

with their regimes.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Treatment outcome literature in depression, investigating whether medication

has an additive effect to therapeutic treatment, has shown mixed results. While some

studies suggest the combination of psychotropic medication and CBT are more

efficacious than either alone (Hollon et al., 1991; Hollon et al., 1992), a number of

other studies have found similar results to that o f this investigation, arguing that

medication does not add anything to the existing therapeutic tool. For instance, in a

quasi-experimental study conducted by Oei and Yeoh (1999), it was hypothesized

that pre-existing medication would enhance treatment outcome for those receiving

group CBT for depression, as compared to those coming into the study not taking

medication. After 12 sessions o f group CBT over a 3-month period, the authors

actually found the opposite of their proposed hypothesis. Results indicated that pre

existing medication did not enhance or detract from the positive treatment outcome

that participants experienced. Although a group format was investigated here, results

are in line with those of this investigation, which also concluded that concurrent drug

intake did not produce an additive effect to the psychotherapy portion of treatment.

In conclusion, the results regarding the additive effect of medication and BA

should be interpreted cautiously as the possible lack of uniformity in medication

regimes and dosages may have biased the results. On the contrary, one cannot

dismiss these findings as the goal of this study was not that of rigorous control, as in

“efficacy” research, but to simulate real-world clinical samples, while also adding to

the smaller body of “effectiveness” research literature. Further research is needed in

this area to uphold these findings (Oei & Yeoh, 1999).

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Limitations of This Study

There are a number of limitations of the current study that merit discussion.

The most notable is the small sample size, due to large attrition rates and difficulty

with recruitment. As noted by Persons, Bums, and Perloff (1988), it is expected that

in controlled research settings, participant dropout rates are lower than those seen in

private clinic settings for several reasons: participants agree to a fixed number of

sessions at the start of treatment, the cost of treatment is typically substantially

reduced, research subjects are likely to be high in motivation given that they must

apply and go through rigorous screening procedures, and great efforts are made by

researchers to follow up missed sessions. Despite similar circumstances in this

investigation, the dropout rate remained relatively high (45%), although not unlike

dropout rates seen in psychiatric community outpatient clinics, which typically range

from 20-60% (Simons, Levine, Lustman, & Murphy, 1984), and other effectiveness

studies that describe a dropout rate between 40-60% (Chambliss & Ollendick, 2001).

Throughout the literature, many reasons for dropping out of treatment

prematurely have been noted. For instance, if a patient shows resistance to change or

to the treatment process itself attrition rates are likely to increase (Davis & Addis,

1999). In this study the therapy itself required patients to learn, utilize and practice

active coping skills on a daily basis. Therefore, high attrition in this study may have

occurred because these participants showed lower levels o f self-efficacy, thus

discontinuing treatment because they could not “buy into the idea” that they were

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. capable o f actively learning and utilizing helpful coping strategies (Davis & Addis,

1999, p. 347).

The high attrition rate in this study possibly could have also been due to

participants’ holding discrepant etiological and treatment beliefs. Furthermore,

patients may have discontinued treatment if they felt a relief from depressive

symptoms, thus assuming treatment was no longer warranted. Family and friends can

also create an environment that fails to support a patient’s response to treatment,

which increases the risk of patient dropout. Many other process variables, such as the

patient’s perceptions o f the therapeutic relationship and sociodemographic variables,

have been shown to affect premature dropout. For instance, research shows that

minorities, patients who are younger, and those who are single/living alone are more

likely to drop out of treatment (Organista, Munoz, & Gonzalez, 1994). Davis and

Addis (1999) report that attrition studies consistently underscore the importance of

such process variables that illustrate the process by which attrition occurs. A better

understanding of such factors may clarify why participants prematurely discontinue

treatment.

Because a clear majority of dropouts in the current study did not give

particular reasons for termination and were unable to be contacted, it is impossible to

know exactly why each person prematurely ended treatment. It may be important to

note that some studies show that increased depressive psychopathology is correlated

with higher levels o f attrition (Fanner, Locke, Liu, & Moscicki, 1994; Murphy,

Carney, Knesevich, Wetzel, & Whitworth, 1995). But in this investigation, increased

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. psychopathology did not appear to be a causal factor in premature termination, as

those who dropped out were not significantly more depressed than those who

completed the study, according to initial pretreatment BDI-H and RHRSD scores.

A number of preventative interventions that target attrition have been cited in

the literature as decreasing the risk o f dropout For instance, Brent, Holder, Kolko,

Birmaher, Baugher, Roth, Iyengar, & Johnson (1997), report that dropouts have been

shown to be more hopeless than those who continue in treatment Therefore ones

hopelessness about the course of treatment could be targeted early on in order to

enhance compliance. Also helpful may be to address attrition directly with the

participant from the beginning of treatment, while making sure the therapist/

participant agree on the conceptualization of his/her problems and the goals and tasks

of therapy. Psychotherapy studies report a threefold increase in attrition rates when

therapists ignore these issues (Epperson, Bushway, & Warman, 1983).

Because of high rates of withdrawal, in conjunction with the lack of further

post-test and follow-up data in this study, the generalizability and external validity of

the results were compromised. Even after collapsing the two treatment groups, the

sample size remained low, which may have had an afreet on the power of the study to

detect real differences if they existed. Also limiting this investigations’

generalizability may have been the restrictive exclusion criteria employed during

recruitment, which in turn, led to studying a narrowly defined population. Although

common practice in clinical trials, this limits our ability to generalize our findings to

the full range of people with depression who seek treatment in a typical service

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. setting. Though, it would be impossible to establish the efficacy of depression

treatment in every conceivable subgroup of depressed individuals, our focus on a

small subset of people with “pure” depression accents how little practicing clinicians

know about comprehensive groups of depressed people (Zimmerman, Mattia, &

Postemak, 2002). Because the presence of simultaneous psychiatric disorders can

greatly modify treatment outcome, it has been repeatedly suggested that researchers

go beyond the study of “pure” depression and broaden their samples to include people

with comorbid diagnoses, such as anxiety and personality disorders, and suicidal

patients (Nezu, Nezu, Trunzo, & McClure, 1998).

Future Investigation and Conclusion

One direction for future BA research may include the obvious move to

broaden the range of patients and settings in which BA appears to be effective. For

instance, testing the effectiveness of BA in other “real-world” and naturalistic settings

(e.g., private practice), with less stringent inclusion criteria (e.g., include those

exhibiting suicidal behaviors and/or other comorbid Axis I and II disorders) could

potentially increase the generalizability of the results.

Along similar lines, future research might test out BA with those suffering

from a more severe and chronic depression. While all but two participants in this

study reported their depression to be recurrent, depression levels fell on the cusp

between moderate and severe, according to the BDI-II. Future studies might consider

a sample in which BDI-II scores average 30 and higher, placing them in the severe

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. category of symptomatology. The severity and chronicity of this disorder has

widespread community implications as both have been correlated with a higher

financial burden to our national community. Research suggests that the more severe

and chronic one’s depression, the more days he or she will lose at work, thus

decreasing overall work productivity (Lecrubier 2001). Given this evidence, it seems

imperative that future BA investigations are geared toward preventing and treating

those suffering from a more severe and chronic depression.

Because o f the aforementioned relapse rates amongst this group, future

investigations might also employ a parametric research strategy, such as exploring a

trial of BA that includes a specified number of intermittent booster sessions. For

example, Nezu et al. (1998) suggests that for an individual with a history of symptom

recurrence, semiannual “depression check-ups” that focus on relapse prevention

techniques maybe useful to maintain treatment gains (p. 509).

While it’s important to know whether a clinically significant reduction in

symptoms has occurred, it is also of central clinical significance to determine whether

the patient’s quality of life (e.g., health status, functional performance, life

satisfaction, standard o f living, etc.) has improved (Gladis, Gosch, Dishuk, & Crits-

Christoph, 1999). Thus, in order to expand our view of clinical significance, future

investigation may use other assessment tools that assess a combination of symptoms,

level of functioning, but also quality of life. More recent instruments, developed

specifically as quality of life measures for depressed patients, such as the Quality of

Life in Depression Scale (Hunt & McKenna, 1992) and the SmithKline Beecham

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Quality of Life Scale (Stoker, Dunbar, & Beaumont, 1992) may be employed along

with more traditional measures as the BDI-H and RHRSD. As noted by Gladis et al.

(1999), a therapeutic intervention is only fully evaluated when its assessment tools

expand beyond symptom severity and the researcher documents its wide effects on all

domains.

The inclusion of quality of life assessments also has implications in the area of

managed care, as providers are developing their own parameters for mental health

that include a wide array of criterion, many o f which bear on the quality of life.

Moreover, managed care providers frequently determine the length and type of

treatment under the quality of life umbrella, which includes such indicators as life

satisfaction, social relationships, and work performance. In sum, the use of quality of

life measures can be viewed as a necessary adjunct to statistical approaches of

defining clinical significance and meaningful change (Jacobson & Traux, 1991).

In order to determine which specific BA interventions are most “necessary,

sufficient, and facilitative” o f therapeutic change (Kazdin, 1992, p. 142), a final

direction may be to conduct an investigation that dismantles BA. This could assist

clinicians in the identification o f BA techniques that are more “user-friendly” for both

the patient and therapist. Moreover, such fine-tuning o f BA may allow researchers

and practitioners to understand the fundamental mechanisms of action in regard to

decreasing overall depressive symptomatology.

Finally, it is important to acknowledge that BA may not be an effective and

preferred therapeutic tool for every person suffering from depression. For instance, it

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. has been suggested by Addis & Jacobson (1996) that patients who show a strong

tendency to search for the causes o f their depression are less likely to experience a

reduction in depressive symptoms with BA treatment. The examination of such

causes may ultimately inhibit and prevent attempts at making meaningful behavior

changes, thus maintaining one’s depression. Because each depressed person shows

great variability in personal characteristics such as life circumstances, symptoms,

developmental history and biological makeup, to suggest BA as the ultimate tool

capable of solving society’s depression epidemic would be to ignore individual

variability (Nezu, 1987).

In conclusion, the results of this investigation affirms that BA shows great

promise as an effective treatment strategy for both medicated and unmedicated

individuals suffering from Major Depressive Disorder. It has been proposed that one

may not need to implement the full CBT treatment package in order to see significant

reductions in symptoms, making BA a sufficient and cost-effective therapeutic tool.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Appendix A

HSIRB Approval Letter

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Insert letter here

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Appendix B

Treatment Integrity Checklist

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. TREATMENT INGREGRITY CHECKLIST

Subject Number ______Session Number Therapist_

1. Client filled out the BDI-II—beginning of session 2. Items on BDI-II were reviewed 3. Therapist & Client set agenda 4. Therapist & Client discussed agenda items 5. Therapist & Client discussed homework(from last week) _ 6. Therapist implementedBehavioral Activation interventions • Functional Assessment • Mastery & Pleasure Ratings of Activities • Daily Activity Schedule Review • Assigning Activities to Increase Sense of Mastery or Pleasure _ • Explained ABC Model to Client • Encouraged an Active Rather than Passive Approach _ • Graded Task Assignments • Mental Rehearsal o f Assigned Tasks/Activities • Examined Alternative Behaviors in Different Situations • Role-Playing Behavioral Assignments • Maximizing the Likelihood of Homework Success • Distraction from Problems or Unpleasant Events • Avoiding or Limiting Exposure to Unpleasant Situations/People • Direct Behavioral Instruction • Taught Client to Give Themselves Rewards • Dealt with Specific Behavior Problems (e.g., sleep) • Training-Social Skills Deficits 7. Therapist did use Cognitive Interventions • Attempted to Change Cognitive Distortions • Addressed Automatic/Dysfunctional Thoughts • Instructed Client to Record Automatic/Dysfunctional Thoughts • Reality Testing of Automatic/Dysfunctional Thoughts 8. Therapist did not use Cognitive Interventions 9. Therapist/Client discussedfollowing week homework

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission Appendix C

Initial Recruitment Telephone Script

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. RECRUITMENT SCRIPT

“The Clinical Researchers at Western Michigan University are conducting a study to assess the effectiveness of a psychological treatment for depression. The treatment is designed to break the cycle of your depression and past research has shown this therapy to be very effective with adults. Treatment would take place once a week for10 consecutive weeks and sessions will last approximately60 minutes. If you are experiencing problems with depression, you are encouraged to schedule an appointment for an intake interview to determine if you qualify for acceptance into the study. Participation in an interview in no way obligates you to participate in the study, but it serves to give both you and the researchers a better understanding of how appropriate the therapy would be for you. If you are accepted into the study, you would be expected to complete the 10-week course of treatment that would require approximately 60 minutes o f your time each week. In addition, you would be expected to perform certain tasks between therapy sessions that are aimed at relieving your depression. Would you like me to go ahead and proceed? I have a few questions I would now like to ask you?” 1. "Are you currently taking any medication fo rpsychological problems? ” Ifves. “what?"______2. Ifves. explain- “In order to participate, we ask that you are stabilized on your medication, meaning you must have been taking itfor at least. 6When weeks d idyou initially start taking your medication?” DATE ______Proceed to Question #3. 3. “Are you currently participating in any sort oftherapy treatmentfar any psychological conditions?______" Ifves. expIain-“/h order to participater we ask that you not be in another concurrent psychosocial treatment.” Give referrals.

If no. ask participants:“Would you like to come in fo r an intake? ”

• Ifves. explain~“I will pass your name and phone number along to my assessor and he/she will call you within the nextfew days to schedule your intake appointment.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Appendix D

Consent Form

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Western Michigan University Department o f Psychology Agreement to Participate in Research

Principal Investigator: C. Richard Spates, Ph.D. Research Associate: Jenifer M. Cullen, M A.

I,______have been invited to participate in a research project entitled “Testing the Effectiveness of Behavioral Activation Therapy in Acute Treatment of Unipolar Depression”. I have been told that this research is intended to measure the efficacy o f Behavioral Activation Treatment as a therapeutic tool to treat individuals suffering from Unipolar Depression. I have been told that this project is Jenifer M. Cullen’s dissertation project. My consent to participate in this project indicates that at the initial intake interview I will be asked to complete one 10-minute multiple choice inventory, along with a brief 5-minute personal information survey. In addition, I will be given two psychological interviews that should take no longer than one hour to administer. Only those persons who qualify for a diagnosis of Unipolar Depression and who are not enrolled in some other concurrent psychosocial therapy will be eligible to participate. Any other diagnoses will exclude me from the study. If I am eligible for the study, I will be randomly assigned to one o f two treatment conditions. In one condition, I will immediately begin Behavioral Activation treatment for depression. In the second condition, Behavioral Activation treatment will be delayed for approximately six weeks. At the end o f the six-week period, I will again be tested with a 10-minute psychological questionnaire and given a 10-minute psychological interview. I will begin treatment immediately thereafter. Both groups will receive treatment for 10 weeks and will be tested weekly with the same 10-minute multiple choice survey. At the end o f the 10-week Behavioral Activation treatment I will again be asked to complete the 10-minute multiple choice survey and then be interviewed with the two psychological interviews given previously. I will also be asked to complete a 5-minute Client Satisfaction Survey. I have also been told that three months after treatment has ended, I will be asked to return to the clinic to complete the same 10-minute multiple choice survey and be interviewed a last time with the two psychological interviews already given. It has been explained to me that there is a possibility that treatment sessions may be videotaped to assure therapy is assuredly executed. Videotapes will be stored in a locked file drawer and only project personnel will have access to those tapes. As in all research, there maybe unforeseen risks to the participant If an accidental injury occurs, appropriate emergency measures will betaken; however, no compensation or treatment will be made available to me except as otherwise specified in this consent form. I realize that one potential risk o f my participation in this project is that I may experience unpleasant emotions, including anger, frustration, depression, and disappointment, as I recall my problems and experiences and actively work to change certain behaviors in order to reduce my depression. I have been told

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. that the Psychology Clinic is prepared to make a referral should emergency care become necessary. I will be responsible for the cost o f emergency care should such care become necessary. One way in which I may benefit from this study is that, as a result o f receiving treatment, I may experience a reduction or elimination o f my depressive symptoms. In addition, I may benefit from the knowledge that is gained by this research, as can others in the community who suffer from Unipolar Depression. I have been told that all research information collected from me will be kept confidential. This means that my name will not appear on any research questionnaires I complete or on any other research forms that contain personal information I have provided. I further understand that these forms will be kept in a research folder in a locked file cabinet in this clinic during my participation in the study. I also have been told that the policy of this clinic requires that progress notes and further information about me be recorded and placed in a treatment folder. This is necessary because by participating in this study, I am also a client of this clinic. However, I realize that the information in my treatment folder belongs to the clinic and may not be used as data for this study. I have been told that forms used in this study may be duplicated and placed in my treatment folder where they will be retained until they are destroyed along with the rest of the papers in my treatment folder according to the policies of the clinic. At the end o f my participation in the study my research folder will be moved to a locked cabinet in the Department of Psychology where it will be stored for at least three years after the completion o f this study. It will then be destroyed. I have been told that Jenifer Cullen will keep a separate master list with the names and research code numbers of participants from this clinic. The master list will be the only link between the data on the recording forms and my identity. The master list will be destroyed once all data has been collected and analyzed. I have been advised that I may refuse to participate or quit at any time during the study without prejudice or penalty or effect on my relationship with Western Michigan University. I am aware o f alternative treatment services should this be the case. If I have any questions or concerns about this study, I may contact either Dr. Richard Spates at (616) 387-4329 or Jenifer Cullen at(616) 553-9836. If I have questions about my rights as a research participant or about any other aspects o f my participation, I also may contact the Chair of the Human Subjects Institutional Review Board at (616) 387-8239 or the Vice President for Research at (616) 387- 8293 with any concerns that I have. This consent document has been approved for use for one year by the Human Subjects Institutional Review Board (HSIRB) as indicated by the stamped date and signature o f the board chair in the upper right comer of all pages. My signature below indicates that the purpose and requirements o f the study have been made clear and that I agree to participate.

Signature______

D ate______

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Demographics Questionnaire

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. DEMOGRAPHICS QUESTIONNAIRE

Research Code Number:______A g e :______D O B : A d d re s s______:

Em ergency C ontact Telephone #______

Gender: (Circle one) Male Female

Ethnicity: (Mark best choice) • African American______• American Indian______• Asian American______• Alaskan American______• Caucasian (w hite)______• H ispanic______• International/non US resident_____ • Multiracial_____ • Other (please specify): ______

Relationship Status: (Mark best choice) • Single, never married______• Living with significant other______• Separated______• Divorced______• M arried______

Years of Education: (Mark best choice) • Less than 12 years______• 12 years or GED ______• More than 12 and less than 16 years • 16 years ______• 16+ years ______

Household Income: (Mark best choice) • Under $10,000 per year______• $10,000-520,000 per year ______• $20,000-530,000 per year ______• Over $30,000 per year ______

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Are you currently receiving treatment for depression? • Y es______• N o ______• If yes, what type of treatment? (Mark all that apply) • Medication Treatment______• Hospital (Inpatient or Partial Hospitalization) Care_____ • Pastoral Care______• Individual Therapy______• Group Therapy ______• Support Group ______

Have you been in treatment for depression in the past? • Y es______• N o ______• If yes, how many episodes of treatment have you been through? _

Are you currently taking prescription medication(s) for depression? • Y es______• N o ______• If yes, what medication(s) are you taking and what is the dosage?

Have you taken prescription medication(s) for depression in the past? • Y es______• N o ______• If yes, what medication(s)?______

Are you currently in treatment for any psychological condition(s) other than depression? • Yes (please specify)______• N o ______

Have you been treated for any psychological conditions(s) other than depression in th e p ast? • Yes (please specify)______• N o ______Current Stressors:

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Appendix F

Beck Depression Inventory—Second Edition

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. The Beck Depression Inventory-Second Edition is copyrighted by Aaron T. Beck, 1996. Persons interested in obtaining information regarding this instrument should contact The Psychological Corporation, 555 Academic Court, San Antonio, Texas 78204-2498.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Appendix G

Revised Hamilton Rating Scale for Depression

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. The Revised Hamilton Rating Scale for Depression is copyrighted by W. L. Warren, 1994. Persons interested in obtaining information regarding this instrument should contact Western Psychological Services, 12031 Wilshire, Boulevard, Los Angeles, California 90025-1251.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Appendix H

Master List

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Master List o f Subjects

Name Last 4 R esearch#

I._

3._

4._

5._

6._

7._

8._

9._

10. II.

12-.

13-.

14-.

15-.

16..

17.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Appendix I

Universal Data Collection Form

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Universal D ata Collection Form

Assessment Information for Participant #

Intake Interview: • BDI-II Score______• RHRSD Score______• SCID DX: • Axis I ____

• Axis II

• Axis III

• Axis IV

• GAF Score

BDI-II scores for WAIT LIST CONDITION ONLY during 6-week wait period

• B D I I _____ • BDI 2 _____ • BDI 3

BDI-Q scores during 10-week treatment:

• W eek 1 ______• W eek 2 ______• W eek 3 ______• W eek 4 ______• Week 5 ______• W eek 6 ______• W eek 7 ______• W eekS ______• W eek 9 ______• W eek 10

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Post-treatment: • B D i-n__ • RHRSD _ • SCID DX: • Axis I

• Axis II • Axis in

• Axis IV

• GAF Score

3 M onth Follow-Up: • b d i-i i _____ • RHRSD____ • SCID DX: • Axis I

• Axis II

• Axis III

• Axis IV

• GAF Score______

• All data collection Complete: Initials Date

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. BIBLIOGRAPHY

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